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3   1822  01077  6144 


UNIVERSITY  OF  CALIFORNIA,  SAN  DIEGO 
LIBRARY  "^rgg^  ^  JOLU.  CALIFORNIA 


UNIVERSITY  OF 
CALIFORNIA 
SAN  DIEGO 


BIOMEDICAL  LIBRARY 
UNIVERSITY  OF  CALIFORNIA,  SAN  DIEGO                   I 
DATE  DUE 

DECS 

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lEC'O 

I'tUV  o 

1988 

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RHTD 

NOV  1 

5  1990 

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CAYLORD 

PRINTED  IN  USA 

Wl  460  S")78i   1889 
UNIVERSITY   OF   CALIFORNIA     SAN   DIEGO  B 


3  1822  01077  6144 


UJ  X- 


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INTESTINAL    SURGERY. 


BY 


K  SEKN,  M.D.,  Ph.D., 


ATTENDING    SUBGEON    MILWAUKEE    HOSPITAL;     PBOFESSOB    PBINCIPLE8    OF    SUBGEBY 

AND    SUBGIOAL    PATHOLOGY,    BUSH    MEDICAL    COLLEGE, 

CHICAGO,    ILL. 


CHICAGO : 

W.    T.    KEEISTEK, 

96  Washington  Stbeet. 
1889. 


■Copyright,  1889,  by  W.  T.  Keener. 


PREFACE. 


There  are  few  subjects  in  practical  surgery  on  which  opinion  is 
more  unsettled  than  on  the  best  method  of  treating  intestinal 
obstruction  and  injuries  of  the  gastro- intestinal  canal.  While  the 
following  pages  are  not  intended  to  serve  the  purpose  of  a  complete 
textbook  on  Intestinal  Surgery,  still  the  author  hopes  that  they  con- 
tain some  new  facts  and  suggestions  which  will  prove  useful  to  those 
who  practice  this  branch  of  surgery. 

The  first  part  of  the  book  contains  a  r6sum6  of  the  best  litera- 
ture on  the  surgical  treatment  of  intestinal  obstruction,  which  has 
been  arranged  in  a  systematic  manner  for  ready  reference.  The 
advice  given  to  the  surgeon  who  is  confronted  by  certain  anatomico- 
pathological  conditions,  is  based  on  clinical  experience  and  the 
results  obtained  by  experimental  investigation. 

The  second  part  represents  the  author's  own  original  work,  made 
with  special  reference  to  the  surgical  treatment  of  intestinal  obstruc- 
tion, and  the  diagnosis  of  perforation  of  the  gastro-intestinal  canal; 
to  which  is  added  the  report  of  three  cases  of  gunshot  wound  of  the 
abdomen,  in  which  inflation  with  hydrogen  gas  proved  a  positive  test 
in  making  a  correct  diagnosis,  before  the  abdomen  was  opened. 

One  of  the  principal  objects  in  publishing  these  papers  in  book 
form  is  a  desire  to  stimulate  the  young  men  in  our  profession  to  enter 
the  field  of  original  investigation,  as  the  author  is  firmly  convinced 
that  experimental  research  constitutes  the  shortest  and  safest  route 
to  the  perfection  of  the  principles  and  practice  of  intestinal  surgery. 

N.  Senk. 
Milwaukee,  December,  1888, 


CONTENTS. 


PAGE 

The  Surgical  Treatment  of  Intestinal  Obstruction,       .  .  - 

[Bead  before  the  Congress  of  American  Physicians  and  Surgeons,  Washington,  1888.] 

I.     Definition  and  Classification  of  Intestinal  Obstruction,  -        4 

II.     Frequency  of  Intestinal  Obstruction,              ...  5 

III.  Surgical  Resources  in  the  Treatment  of  Intestinal  Obstruction,       6 

1.  Irrigation  of  the  Stomach,               ....  g 

2.  Distention  of  Colon  with  Fluids,           -            -            -  -8 

3.  Rectal  Insufflation  of  Hydrogen  Gas,          -             -             -  12 

4.  Tub  age  of  Colon,            -            -            -             -            -  -      16 

6.     Manual  Exploration  by  the  Rectum,          -             -            -  18 

6.  Taxis  and  Massage,        -      ,      -             -             -            -  -      19 

7.  Puncture  of  Intestines,        -             -       •      -             -             -  20 

8.  Uniform  and  Uninterrupted  Compression  of  Abdomen,.  -      22 

9.  Enterotomy,               ..-.-.  22 

10.  Colotomy,  .......      25 

11.  Abdominal  Section,               .....  27 

a.  Preparation  for  the  Operation,      -             -             -  -      32 

b.  Anaesthesia,         ------  33 

c.  Incision,       -            -            -            -            -            -  -34 

d.  Intra-Abdominal  Examination,             -             -             -  36 

e.  Operative  Treatment  of  Obstruction,        -            -  -      43 

1.  Intestinal  Anastomosis,     -            -            -            -  43 

2.  Physiological  Exclusion  by  Anastomosis,      -  -      62 

3.  Laparo-Enterotomy,           -             -             -             -  62 

4.  Enterectomy,                  -             -             -             -  -      54 

5.  Direct  Treatment  in  Strangulation  by  Band,  Diver- 

ticula, Flexion  and  Adhesions,       -             -  -      57 

6.  Toilette  of  Peritoneal  Cavity,       -             -             -  60 

7.  After-Treatment,           -             -             -             -  -      61 

IV.  Anatomico-Pathological  Forms  of  Intestinal  Obstruction,  62 
1.     Entero-Lithiasis,              -             -             -             -             -  -      62 

a.  Biliary  Calculi,                -             -             -             -             -  62 

b.  Intestinal  Concretions,        -             -             -             -  -      72 

c.  Parasites  as  a  cause  of  Intestinal  Obstruction,          -  74 

d.  Faecal  Obstruction,                -             -             -             -  -      76 


VI-  CONTENTS. 

PAGE 

IV.  Anatomico-pathological     Forms     of     Intestinal     Obstruction, 

(Continued),  ----.. 

2.     Invagination,             ------  78 

Pathology  of  Acute,              -             -             -  .             -      83 

Pathology  of  Chronic,                -             -  -             -             86 

Treatment,                 -             -             .             -  .             -      87 

Rectal  Insufflation  of  Hydrogen  Gas,  -             -             88 

Colotomy,         -             -             .             .  .             -      89 

Enterotomy,           -             -  -            -            90 

Laparotomy,                 -            .            .  .            -      91 

Disinvagination,                -            -  -            -            94 

Intestinal  Anastomosis,           -            .  .            -      95 

Resection,               -             -            .  .            .            gg 

3.  Volvulus,              -            -             -            .             .  .            -98 

Treatment,  ---...  iq^ 

4.  Flexion  and  Adhesions,"  ....    lOi 
6.     Ligamentous  Bands  and  Diverticula,  -  -  -  no 

6.  Stenosis,  -  -  -  -  .  ...    ^21 

1.  Congenital,         ---,..  121 

2.  Acquired  or  Cicatricial,       -  -  .  .  .    123 

7.  Tumors,  -  -  -  -  .  .  i27 

1.     Non-Malignant,  ----..  128 

•     2.     Malignant,          -            -            .            .            .            -  129 

a.  Sarcoma,  --....  129 

b.  Carcinoma,               -             -             .                           .  131 

V.  Dynamic  Intestinal  Obstruction,  -  .  -  .    134 

1.  Tympanites,  -----.  134 

2.  Peritonitis,         ----...  135 

3.  Catarrhal  and  Ulcerative  Enteritis,  -  -  -  137 

4.  Exventration,    ----...  133 

An  Experimental  Contribution  to  Intestinal  Surgery,  with  Special  Refer- 
ence to  the  Treatment  of  Intestinal  Obstruction,     -  -  -    I4i 
[Reprinted  from  "Annals  of  Surgery,"  by  permission.] 
General  Remarks  on  Experiments,      -             -             -             -  144 
I.     Artificial  Obstruction,         ---._.    hq 

1.  Stenosis,       ...  ...  hq 

a.  Partial  Enterectomy,         -  .  .  .  .  hq 

b.  Circular  Constriction,  -  .  -  147 

2.  Flexion,  -  .  .  149 

3.  Volvulus,      -  -  -  ...  151 

4.  Invagination,    ----...  152 

Permeability  of  Ileo-Caecal  Valve,     -  -  -  167 

II.     Enterectomy,  ----...  153 

Excision  of  Colon,  -  -  -  .  .  lei 

Physiological  Exclusion,  -  -  .  .  .  163 


CONTENTS.  vii. 

PAGE 

III.  Circular  Enterorrhaphy,  -  -  .  .  .  iqq 

Nothnagel's  Test,  ---...    171 

Transplantation  of  Omental  Flap,  ...  172 

IV.  Intestinal  Anastomosis,      --....    177 

Directions  for  Preparing  Bone  Plates,     -  -  -  179 

1.  Gastro-Enterostomy,    ---...  iQO 

2.  Jejuno-Ileostomy,  .....  133 

3.  Ileo-Colostomy,  ......  139 

4.  Ileo-Rectostomy,     -  -  -  -  .  -  197 

5.  Colo-Rectostomy,  -.-...  193 

V.     Adhesion  Experiments,  .....  199 

1.  Traumatic  Irritation  of  Serous  Surfaces,       -  -  -  200 

2.  Chemical  Irritation  of  Serous  Surfaces,  -  -  203 

3.  Omental  Grafting,         ------  205 

VI.     Conclusions,       -  -  -  -  .  .  2O8 

Bectal  Insufflation  of  Hydrogen  Gas  an  Infallible  Test  in  the  Diagnosis  of 
Visceral  Injury  of  the  Gastro-Intestinal  Canal  in  Penetrating 
Wounds  of  the  Abdomen,        --.-.-    215 

[Read  before  the  American  Medical  Association,  1888.J 

I.     Permeability  of  the  Ileo-Csecal  Valve,  -  -  218 

1.  Rectal  Insufflation  of  Air,       -----  222 

2.  Inflation  through  Stomach  Tube,  -  -  -  225 

3.  Pressure  Experiments,  Ileo-C£ecal  Valve,      -  -  -  227 

4.  Pressure  Experiments  to  force  Gas  through  entire  Alimen- 

tary Canal,  ......    229 

II.     Resistance  of  Gastro-Intestinal  Canal  to  Diastaltic  Force,  -  231 

1.  Stomach,           -             -             -             -             -             -  -    231 

2.  Small  Intestines,                 -----  232 

3.  Colon,                -             -             -             -             -             -  -    232 

III.  Distention  of  Gastro-Intestinal  Canal  by  Rectal  Insufflation  of 

Hydrogen  Gas,  ......    233 

IV.  Hydrogen  Gas  is  Innocuous  and  Non-Irritating  when  brought 

in  Contact  with  Living  Tissues,  and  is  Promptly  Removed 
by  Absorption,       -...--  238 

1.  Peritoneal  Cavity,        -  -  -  -  -  -    238 

2.  Pleural  Cavity,      -  -  -  -  -  -    ■       239 

3.  Subcutaneous  Cellular  Tissue,  _  .  .  .    239 
V.     Rectal  Insufflation  of  Hydrogen  Gas  in  the  Diagnosis  of  Pene- 
trating Gunshot  Wounds  of  the  Abdomen,         -             -  239 

Inflation  of  the  Stomach  with  Hydrogen  Gas  in  the  Diagnosis  of  Wounds 

and  Perforations  of  this  Organ,  with  the  Report  of  a  Case,  -    249 

Two  Cases  of  Gunshot  Wound  of  the  Abdomen,  Illustrating  the  Use  of 

Rectal  Insufflation  with  Hydrogen  Gas  as  a  Diagnostic  Measure,        253 


INTESTINAL  SURGERY. 


THE    SURGICAL   TREATMENT   OF   INTESTINAL 

OBSTRUCTION. 


The  operative  treatment  of  intestinal  obstruction  is  in  its 
infancy.  Since  laparotomy  for  other  indications  has  become  an 
established  and  frequently  practiced  procedure,  a  number  of  the 
bolder  and  more  a^sressive  surgeons  have  resorted  to  direct  meas- 
ures  for  the  relief  of  intestinal  obstruction,  but  like  all  serious 
operations  for  otherwise  incurable  and  fatal  affections  its  general 
application  has  met  with  strong  opposition  not  only  by  the  laity,  but 
also  by  the  profession.  The  appalling  mortality  which  has  attended 
the  operations  in  the  hands  of  even  the  most  competent  surgeons  has 
been  a  sufficiently  strong  argument  for  non-operative  interference. 

In  this  regard  the  history  of  laparotomy  for  intestinal  obstruc- 
tion is  only  a  repetition  of  the  histoiy  of  ovariotomy.  During  the 
early  part  of  the  latter,  the  mortality  was  so  great  that  the  operation 
was  condemned  and  denounced  as  a  deliberate  murder  by  some  of 
the  ablest  and  most  influential  surgeons.  Yet  in  spite  of  all  opposi- 
tion the  good  work  progressed  until  by  an  improved  technique,  and 
more  especially  the  introduction  of  antiseptic  surgery,  ovariotomy 
in  the  hands  of  experts  has  become  one  of  the  safest  operations  in 
surgeiy.  To  accomplish  this  hundreds  of  lives  were  sacrificed  that 
thousands  might  be  saved.  The  early  ovariotomists  operated  only  on 
patients  worn  out  by  the  disease  and  often  the  subjects  of  additional 
serious  visceral  lesions  caused  by  the  prolonged  intra-abdominal 
pressure,  the  reason  for  this  being  the  great  mortality  which  attended 
the  operation.  To-day  the  danger  incident  to  opening  the  abdominal 
cavity  under  proper  antiseptic  precautions  is  so  slight  that  patients 
suffering  from  ovarian  tumors  are  encouraged  to  have  them  removed 
as  soon  as  their  presence  can  be  diagnosticated,  at  a  time  when  the 


2  INTESTINAL  SURGERY. 

general  health  remains  unimpaired,  a  change  of  practice  which  has 
still  further  reduced  the  mortality  of  ovariotomy.  The  mortality  of 
laparotomy  for  acute  intestinal  obstruction  will  be  reduced  to  that  of 
other  intraperitoneal  operations  as  soon  as  surgeons  will  recognize 
the  importance  of  operating  early,  before  the  patient's  strength  has 
been  wasted  by  the  disease,  and  before  the  parts  involved  in  the 
operation  have  undergone  irreparable  textural  changes.  The  mor- 
tality of  abdominal  section  in  the  treatment  of  the  different  forms 
of  intestinal  obstruction  will  always  be  great,  because  the  conditions 
which  have  caused  the  obstruction  are  often  an  intrinsic  source  of 
danger.  In  others,  the  removal  of  the  obstruction  necessitates  an 
intestinal  resection  which  in  itself  is  a  vastly  more  serious  opera- 
tion than  the  removal  of  an  ovarian  tumor.  Intestinal  obstruction, 
irrespective  of  its  cause,  is  always  followed  by  a  series  of  consecutive 
pathological  changes  which  independently  of  the  partial,  or  com- 
plete interruption  of  the  passage  of  intestinal  contents  tend  to 
destroy  life. 

The  dilatation  of  the  intestinal  tube  on  the  proximal  side  of 
the  seat  of  obstruction  may  give  rise  to  such  a  degree  of  abdom- 
inal distention  as  to  destroy  life  from  suspension  of  important 
fuactions  by  mechanical  pressure.  In  acute  obstruction,  the  violent 
peristalsis  on  the  proximal  side  of  the  occlusion  causes  an  increased 
afflux  of  blood  to  the  portion  of  bowel  the  seat  of  exaggerated  phys- 
iological function,  which  after  cessation  of  peristaltic  action  remains 
as  an  intense  venous  and  capillary  engorgement.  During  the  paretic 
stage  the  blood  vessels  in  the  intestinal  wall  have  lost  their  extra 
vascular  support,  hence  transudation  and  exudation  readily  take 
place  into  the  paravascular  tissues,  which,  combined  with  the 
capillary  stasis  attending  this  stage  of  the  inflammatory  process, 
often  results  in  gangrene.  The  intestinal  wall,  in  a  state  of  inflam- 
mation, becomes  permeable  to  pathogenic  micro-organisms  which 
are  always  present  in  the  intestinal  canal,  and  which  after  passing 
through  the  entire  thickness  of  its  walls  enter  the  peritoneal  cavity 
and  induce  septic  peritonitis,— a  frequent  immediate  cause  of  death. 
These  facts  are  cogent  reasons  for  adopting  surgical  measures  in  all 
cases  of  intestinal  obstruction  due  to  mechanical  causes  as  soon  as 
a  probable  diagnosis  can  be  made.  If  this  were  done,  the  two 
greatest  sources  of  immediate  danger  attending  and  following 
laparotomy,  shock  and  septic  peritonitis,  if  not  entirely  avoided,  at 


OPERATIVE  TREATMENT  OF  INTESTINAL  OBSTRUCTION.         O 

least  would  be  less  likely  to  occur,  and  the  tissues  the  seat  of  oper- 
ation would  be  in  ai  favorable  condition  for  direct  treatment  and 
repair.  An  abdominal  section  in  the  treatment  of  intestinal  obstruc- 
tion is  always  necessarily  attended  by  some  shock,  and  it  is  therefore 
of  the  utmost  importance  to  perform  the  operation  at  a  time  when 
the  organs  of  circulation  and  the  nervous  system  are  still  in  a  condi- 
tion to  successfully  resist  the  immediate  efPects  of  the  operation. 
Death  from  septic  causes  can  only  be  avoided  by  operating  at  a  time 
when  the  intestinal  canal  at  the  seat  of  obstruction  and  on  its  prox- 
imal side  is  still  in  a  condition  capable  of  resisting  infection  and  of 
undergoing  a  satisfactory  process  of  repair  in  case  it  becomes 
necessary  to  incise,  or  resect  during  the  operation.  The  statistics 
of  operations  for  intestinal  obstruction  will  improve  as  soon  as  we 
shall  be  able  by  improved  methods  of  diagnosis  to  make  an  early 
positive  diagnosis  and  to  adopt  in  the  treatment  positive  surgical 
measures  before  the  prospects  of  a  recovery  have  been  rendered 
improbable,  if  not  impossible,  by  days  and  weeks  of  useless,  and 
worse  than  useless,  internal  medication.  True  intestinal  obstruction, 
whatever  its  cause  may  be,  is  as  strictly  a  surgical  aflPection  as 
strangulated  hernia  and  remediable  only  by  the  same  kind  of  surgi- 
cal treatment.  Physicians  should  recognize  this  fact  and  should 
call  into  counsel  a  surgeon  as  soon  as  a  probable  diagnosis  of 
intestinal  obstruction  can  be  made.  To  let  a  patient  die  of  the 
consequences  of  a  removable  cause  of  obstruction  without  an  opera- 
tion is  a  reflection  upon  the  advances  of  modern  aggressive  surgery. 
The  difficulties  which  surround  the  diagnosis  and  the  present 
imperfect  technique  of  the  operative  procedures  in  cases  of  intes- 
tinal obstruction  are  not  only  responsible  for  the  heretofore  late 
operations,  but  also  to  a  great  extent  for  the  many  failures.  Ways- 
and  means  for  more  accurate  diagnosis  will  have  fco  be  devised  by 
more  careful  clinical  observations  and  by  experimental  research, 
while  new  and  improved  methods  of  operation  must  be  devised  and 
their  merits  and  safety  tested  by  experiments  on  animals.  I  am  con- 
vinced that  accurate  experimental  work  of  this  kind  will  render 
essential  information  in  the  diagnosis  of  the  obscure  causes  of  ob- 
struction, and  will  point  out  more  clearly  the  indications  for  opera- 
tive treatment,  while  improved  methods  of  operation  will  have  to 
be  studied  exclusively  in  this  manner.  The  obstacles  which  the 
surgeon  encounters  in  the  diagnosis  and  treatment  of  many  cases  of 


4  INTESTINAL  SURGERY. 

intestinal  obstruction  often  appear  insurmountable,  but  they  will  be 
greatly  diminished  in  the  future  by  facts  which  will  be  revealed 
by  the  results  of  experimental  investigation.  Abdominal  surgery 
was  founded  and  developed  on  American  soil,  and  in  the  part  which 
refers  to  the  treatment  of  intestinal  obstruction,  ample  scope  is  left 
for  the  exercise  of  the  genius  and  perseverance  of  the  younger 
members  of  the  profession  in  this  country,  who  would  do  honor  to 
the  memory  of  our  McDowell,  our  Sims,  and  our  Gross  by  honest, 
faithful,  unselfish,  original  work. 

I.    Definition  of  Intestinal  Obstruction. 

Intestinal  obstruction,  occlusion  and  strangulation  have  been 
used  as  synonymous  terms.  Some  authors  wish  to  draw  a  line  of 
distinction  between  cases  of  intestinal  obstruction  and  intestinal 
strangulation,  including  under  the  former  term  all  cases  where  the 
obstruction  is  caused  by  9,  tumor,  enterolith,  or  intussusception, 
while  internal  hernia,  volvolus,  and  constriction  by  a  band  are 
included  under  the  head  of  strangulation.  For  practical  purposes 
such  a  distinction  is  superfluous,  as  any  cause  which  mechanically 
interferes  with  the  passage  of  intestinal  contents  produces  intestinal 
obstruction,  and  if  it  cannot  be  removed  by  ordinary  means  should 
be  treated  by  abdominal  section.  The  classification  into  true  and 
false  obstruction,  from  a  surgical  standpoint,  should  also  be  aban- 
doned, as  operative  interference  is  only  indicated  in  cases  of  obstmc- 
tion  due  to  the  presence  of  mechanical  obstacles,  such  as  foreign 
bodies,  tumors,  or  intussusceptum  in  the  lumen  of  the  bowel,  or  to 
compression  of  the  lumen  by  tumors,  flexion,  twisting,  and  bands  of 
.constriction.  Inflammation  of  the  tunics  of  the  bowel  and  diffuse 
peritonitis  may  give  rise  to  symptoms  resembling  obstruction,  but  in 
such  cases  the  obstruction  follows  as  a  sequence  of  an  antecedent 
or  accompanying  inflammatory  lesion,  and  is  due  to  dynamic  dis- 
turbances and  not  to  mechanical  occlusion,  and  the  indications  for 
treatment  are  to  combat  the  inflammation  and  to  restore  peristaltic 
action,  combined  with  mechanical  means  to  relieve  the  abdominal 
distention.  A  more  important  classification  remains  to  be  mentioned 
by  which  all  cases  of  true  intestinal  obstruction  are  divided  into 
acute  and  chronic.  This  distinction  must  be  maintained  for  many 
reasons.  In  chronic  obstruction  the  symptoms  usually  develop  veiy 
slowly  as  the  occlusion  becomes  more  complete.      During  the  early 


FREQUENCY   OF  INTESTINAL    OBSTRUCTION.  5 

part  of  the  affection  the  intestinal  walls  above  the  seat  of  obstruction 
undergo  compensatory  hypertrophy,  dilatation  taking  place  very 
slowly  unless  the  chronic  suddenly  merges  into  the  acute  form,  an 
event  which  is  always  announced  by  a  complesus  of  symptoms  charac- 
teristic of  acute  or  subacute  obstruction.  Chronic  obstruction  is  more 
frequently  met  with  in  persons  advanced  in  years,  and  the  seat  of 
obstruction  is  usually  located  in  some  part  of  the  large  intestines. 
The  acute  form  is  caused  by  some  pathological  conditions  which 
suddenly  narrow,  or  obliterate  the  lumen  of  some  portion  of  the 
intestine,  usually  above  the  ileo-caecal  valve,  and  often  without  any 
premonitory  symptoms  gives  rise  to  a  complexus  of  acute  symptoms 
almost  pathognomonic  of  this  afPection.  The  sudden  interruption 
of  the  passage  of  intestinal  contents  is  followed  by  violent  peri- 
staltic action  of  the  bowel  above  the  seat  of  obstruction  in  a  vain 
attempt  to  clear  the  intestinal  tract,  which  from  muscular  exhaus- 
tion and  the  distention  from  the  accumulation  of  intestinal  con- 
tents finally  gives  rise  to  paresis  and  the  textural  changes  pre- 
viously alluded  to.  In  the  treatment  of  such  acute  cases  prompt 
action  constitutes  an  essential  element  of  success,  as  in  a  few 
hours,  or  days,  the  patient  becomes  utterly  prostrated,  and  the 
bowel  at  and  above  the  seat  of  obstruction  has  undergone  irrepar- 
able pathological  changes.  These  are  the  cases  that  demand  early 
surgical  treatment,  and  that  now  claim  our  special  attention. 

II.    Frequency  of  Intestinal  Obstruction. 

"  An  examination  of  the  statistics  of  Leichtenstem'  shows  that, 
external  hemise  and  malignant  tumors  being  excluded,  one  death 
from  intestinal  obstruction  takes  place  in  every  three  to  five  hun- 
dred deaths  from  all  causes  in  hospital  practice.  This  statement 
is  based  upon  the  records  of  the  late  Dr.  Brinton,  of  London,  and  a 
mimber  of  large  hospitals  on  the  European  continent. 

Hilton  Fagge'^  has  shown  from  an  examination  of  the  records 
of  four  thousand  autopsies  in  Guy's  Hospital,  from  1854  to  1868, 
that  fifty-four,  or  about  one-fourth  per  cent.,  were  cases  of  intestinal 
obstruction. 

1  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine,  American  Transla- 
tion, Vol.  VIII.  * 

2  Guy's  Hospital  Reports,  1869. 


6  INTESTINAL   SURGERY. 

Heusner'  from  his  own  investigations  regarding  the  frequency 
of  intestinal  obstruction  maintains  that  annually  out  of  every  one- 
hundred  thousand  individuals,  from  five  to  ten  suffer  from  this 
affection,  and  that  one  to  every  three  to  five  hundred  deaths  is 
attributable  to  this  cause.  These  statistics  show  the  importance  of 
intestinal  obstruction  in  its  medical  and  surgical  relations,  and  it  is 
hoped  that  by  their  aid  new  light  may  be  shed  upon  a  class  of 
affections  which  heretofore,  only  too  often,  have  baffled  the  skill  of 
both  physician  and  surgeon. 

III.     Surgical  Resources  in  tlie  Treatment  of  Intestinal 

Obstruction. 

I.    Irrigation  of  Stomach. 

The  accumulation  of  intestinal  contents  above  the  seat  of  ob- 
struction acts  deleteriously  in  several  ways:  1.  It  causes  violent 
peristaltic  action  of  the  intestine  above  the  seat  of  obstruction. 
2.  It  exhausts  the  patient's  strength  by  causing  persistent  retch- 
ing and  vomiting.  3.  It  is  one  of  the  causes  which  produces 
distention  of  the  intestine.  4.  It  favors  fermentative  and  putre- 
factive changes  in  the  intestine  by  the  fluid  serving  the  purpose  of 
a  nutrient  medium  for  pathogenic  micro-organisms.  In  my  experi- 
ments on  animals  where  I  made  complete  obstruction  I  never 
witnessed  such  persistent  vomiting  as  in  man.  I  attributed  this 
difference-  to  the  fact  that  animals  thus  treated  refuse,  as  a  rale, 
both  food  and  drink,  and  that  the  intestinal  canal  in  proportion  to 
the  size  of  the  abdominal  cavity  is  much  shorter  than  in  man. 
Patients  suffering  from  acute  intestinal  obstruction  should  abstain 
from  taking  either  food  or  drink,  as  digestion  and  absorption  are 
almost,  if  not  completely,  suspended,  and  the  accumulation  of 
fluids  cannot  fail  in  aggravating  the  symptoms. 

KussmauP  has  introduced  a  new  and  exceedingly  valuable 
therapeutic  measure  in  the  treatment  of  intestinal  obstruction  in 
the  use  of  the  elastic  stomach-tube.  By  the  siphon  action  of  the 
tube,  gas  and  the  fluid  contents  of  the  stomach  and  upper  portion 
of  the  intestinal  canal  are  evacuated,  and  thus  abdominal  distention 
is  relieved  and  the  hydrostatic  pressure  in  the  intestine  above  the 

1  Deutsche  Med.  Wochenschrift,  1887. 

2  Bed.  Klin.  Wochenschrift,  Nos.  42,  43,  1884. 


SURGICAL  RESOURCES  IN   TREATMENT.  i 

obstruction  diminished.  He  claims  for  this  measure  the  following 
advantages:  1.  Intra-abdominal  tension  is  diminished  and  thus  the 
first  condition  secured  for  the  coiTection  of  the  mechanical  diflficulties 
which  have  caused  the  obstruction.  2.  It  relieves  the  distention  of 
the  bowel  above  the  seat  of  obstruction  and  consequently  also  the 
pressure  of  the  intestines  against  each  other,  a  condition  .which 
cannot  fail  to  impair  peristaltic  action.  3.  Finally,  what  is  most 
important,  by  evacuating  the  accumulated  contents  it  diminishes 
the  violent  peristalsis.  He  reports  the  case  of  an  adult  where  an 
intestinal  obstruction  due  to  an  invagination  had  lasted  twenty-three 
days  and  which  yielded  to  daily  irrigations  of  the  stomach.  A 
portion  of  the  intussuscepttun  sloughed  and  was  found  in  the  stool. 
The  patient  died  later  of  peritonitis  which  may  have  started  from 
the  seat  of  invagination. 

Bardeleben^  in  a  paper  on  the  treatment  of  acute  intestinal 
obstruction,  praises  the  utility  of  irrigation  of  the  stomach  as  a 
palliative  means,  but  speaks  at  the  same  time  of  the  danger  inci- 
dent to  the  employment  of  such  a  temporizing  measure,  as  too  much 
valuable  time  may  be  lost  before  a  curative  treatment  is  adopted. 
He  reports  a  case  in  which  irrigation  afforded  such  absolute  relief 
that  the  operation  was  postponed  vintil  it  could  be  no  longer  of  any 
avail.  Kuester  expects  from  irrigation  of  the  stomach  prompt  pallia- 
tive effects,  but  warns  not  to  persist  with  it  in  cases  where  the  seat 
and  cause  of  the  obstruction  can  be  ascertained.  Hahn  looks  upon 
it  as  a  curative  agent  only  in  cases  where  the  obstruction  is  due  to 
koprostasis  in  the  large  intestines,  and  he  claims  that  in  such  cases 
irrigation  of  the  rectmn  would  lead  more  promptly  to  the  desired 
result. 

SchlegtendaP  claims  that  lavage  of  the  stomach  in  the  treat- 
ment of  intestinal  obstruction  fulfills  a  threefold  therapeutic  indica- 
tion: 1.  It  prevents  distressing  symptoms;  2.  alleviates  them  when 
they  are  present;  and  in  some  cases  3.  cures  the  disease. 

Kehn^  mamtains  that  irrigation  of  the  stomach,  as  devised  by 
Kussmaul,  in  the  treatment  of  intestinal  obstruction  not  only  empties 
the  stomach  of  its  contents,  but  it  also  evacuates  a  certain  portion 
of  the  intestinal  canal  above  the  seat  of  obstruction.     In  two  cases 

1  Ueber  Ileus.  Berl.  Klin.  Wochenschrift,  Nos.  25,  26,  1885. 

2  Frauenarzt,  1887. 

^  Fortschritte  der  Medicin,  1887. 


8  INTESTINAL  SURGERY. 

of  intestinal  obstruction,  where  this  expedient  was  resorted  to  after 
the  abdominal  cavity  was  opened,  he  observed  that  a  considerable 
portion  of  the  dilated  intestine  was  emptied  of  its  contents. 

Heusner  states  that  by  this  means  many  litres  of  intestinal 
contents  can  be  removed,  pain  is  relieved,  eructation  and  vomiting 
controlled,  peristalsis  quieted,  the  function  of  the  stomach  restored, 
suitable  nourishment  can  be  taken  and  assimilated,  thus  maintaining 
strength  and  life  until  the  cause  of  obstruction  is  removed  sponta- 
neously, or  through  the  intervention  of  surgery.  Madelung  has 
called  attention  to  the  necessity  of  resorting  to  irrigation  of  the 
stomach  prior  to  the  administration  of  an  anaesthetic  in  operations 
for  intestinal  obstruction,  as  without  such  precaution  there  is  danger 
during  the  attacks  of  vomiting  which  are  almost  sure  to  be  provoked 
by  the  anaesthetic,  of  fluid  entering  the  trachea,  causing  suffocation, 
or  later,  pneumonia.  As  an  aid  in  the  treatment  of  intestinal  ob- 
struction due  to  mechanical  causes,  irrigation  of  the  stomach  should 
always  be  systematically  practiced  every  four  to  six  hours,  but  as  a 
curative  measure  it  should  never  be  relied  upon.  In  my  own  prac- 
tice I  have  always  combined  emptying  of  the  stomach  with  irrigation, 
using  large  quantities  of  warm  water  rendered  antiseptic  by  the  addi- 
tion of  salicylated  soda,  or  hypophosphite  of  soda.  The  washing  out 
of  the  stomach  with  a  harmless  and  efficient  antiseptic  solution,  has  a 
decided  beneficial  effect  in  preventing  fermentative  and  putrefactive 
chansfes  in  the  intestinal  contents  above  the  seat  of  obstruction. 


&^ 


•  2.    Distention  of  Colon  with  Fluids. 

Evacuation  of  the  colon  by  copious  rectal  injections  is  resorted 
to  almost  instinctively  in  every  case  of  intestinal  obstruction.  This 
procedure  has  also  been  employed  with  the  intention  of  utilizing 
the  hydrostatic  pressure  as  a  means  for  the  correction  of  the 
mechanical  difficulties  which  have  given  rise  to  the  obstruction. 
This  method  of  treatment  has  given  rise  to  the  much  discussed  ques- 
tion as  to  the  permeability  of  the  ileo-csecal  valve  to  rectal  injections 
of  fluids,  or  to  the  insufflation  of  air  or  gases.  The  majority  of 
those  who  have  studied  this  subject  clinically  or  by  experiment  make 
the  positive  assertion  that  the  ileo-csecal  valve  is  perfectly  compe- 
tent and  effectually  guards  the  ileum  against  the  entrance  of  both 
fluids  and  gases  forced  into  the  rectum,  while  others  insist  that  it  is 


DISTENTION    OF   COLON    WITH  FLUIDS.  9 

permeable  only  in  exceptional  cases,   and  only  a  few  claim  that  its 
resistance  can  be  overcome  by  a  moderate  degree  of  pressure. 

Heschl'  made  a  number  of  experiments  on  the  cadaver  and 
satisfied  himself  that  the  ileocsecal  valve  serves  as  a  safe  and  perfect 
ban'ier  against  the  entrance  of  fluids  from  below.  In  testing  the 
resisting  capacity  of  the  coats  of  the  intestine  he  found  that  the 
serous  coat  of  the  colon  gave  way  first  to  over-distention,  while  the 
remaining  tunics  yielded  subsequently  to  a  somewhat  slighter  pres- 
sure. The  small  intestine  of  a  child  on  being  subjected  to  over- 
distention  ruptured  first  on  the  mesenteric  side,  the  place  where 
acquired  diverticula  are  found. 

'  Bull''  has  found  that  in  the  adult  one  litre  of  water  injected  by 
the  rectum  will  reach  the  csecum,  but  that  the  entire  capacity  of  the 
large  intestine  is  from  4  to  5  litres.  He  is  of  the  opinion  that  in 
the  living  body  fluid  cannot  be  forced  beyond  the  ileo-csecal  valve, 
although  ancient  and  modern  experimenters  claim  to  have  succeeded 
in  the  cadaver.  He  affirms  that  when  the  rectum  is  distended  by  air 
the  ileo-csecal  valve  is  rendered  incompetent  and  the  air  passes  into 
the  small  intestines.  Cantani^  is  a  firm  believer  in  the  permeability 
of  the  ileo-csecal  valve  to  fluid  rectal  injections.  In  one  instance  he 
treated  a  case  of  coprostasis  by  an  injection  of  a  litre  and  a  half  of 
oil  per  rectum,  and  an  hour  later  a  part  of  the  oil  was  ejected  by 
vomiting.  He  advises  that  the  intestinal  tract  above  the  ileo-csecal 
valve  should  be  utilized  as  an  absorbing  surface  in  cases  requiring 
rectal  alimentation,  and  when  in  a  diseased  condition  should  be 
treated  by  topical  applications. 

Behrens*  concluded  from  his  experiments  that  it  required  the 
insufflation  per  rectum  of  one  and  one- eighth  litres  of  air  to  reach 
the  ileum  through  the  ileo-csecal  valve.  In  his  experiments  he  had 
no  difficulty  in  overcoming  the  competency  of  the  ileo-csecal  valve 
by  rectal  insufflation  of  air. 

Debierr6^  made  numerous  experiments  on  the  cadaver  to  test 

iZur  Mechanik  der  Diastaltischen  Darmperforationen,  Wiener  Med. 
Wochenscrift,  No.  1,  1881. 

2Virchow  u.  Hirsch's  Jahresbericht,  B.  2,  1870,  p.  180. 

^Virchow  u.  Hirsch's  Jahresbericht,  B.  2,  1879,  p.  180. 

*Ueber  den  Werth  der  kunstlichen  Auftreibung  des  Dickdarmes  mit  Gasen 
u.  Flassigkeiten.      Dissertation.     Gottingen,  1886. 

^  La  valvule  de  Banhin  considere  comme  barriere  des  apothecaires.  Lyon 
Medicale,  No.  45,  1885. 


10  INTESTINAL  SURGERY. 

the  permeability  of  the  ileo-csecal  valve  to  rectal  injections  of  jluids 
or  insufflation  of  air.  The  results  which  he  obtained  were  not  con- 
stant. In  some  subjects  the  valve  proved  only  permeable  to  air;  in 
others,  to  both  air  and  water;  while  in  some  no  air  nor  fluids  could 
.be  forced  into  the  ileum  by  any  degree  of  force.  When  the  intestine 
was  left  in  situ  the  valve  was  found  less  permeable  than  when 
the  intestine  had  been  removed  from  the  body.  He  attributes  the 
different  degrees  of  competency  of  the  valve  to  variations  in  the 
anatomical  construction  of  the  valve.  If  both  lips  of  the  valve  are 
equal  in  length,  or  if  the  lower  lip  is  longer,  the  valve  was  found 
impermeable.  It  proved  permeable  in  cases  where  the  lower  lip 
was  shorter,  contracted,  and  smaller  than  the  upper.  In  the  last 
instance,  the  advancing  volume  of  fluid  or  air  lifted  the  upper  valve, 
while  in  the  former  structure  of  the  valve,  the  margins  of  the  lips  of 
the  valve  were  approximated,  perfectly  shutting  off  all  communica- 
tion between  the  colon  and  the  ileum. 

Mr.  Lucas'  enumerates  the  following  objections  against  forcible 
rectal  injections  of  water  as  a  means  to  reduce  an  invagination: 

1.  Owing  to  its  weight  it  exerts  much  too  strong  lateral  pres- 
sure for  the  intestine  safely  to  bear,  and  he  has  found  it  easy  to 
rupture  the  bowel  after  death  by  forcing  in  water. 

2.  Should  reduction  have  been  accomplished  the  contact  of  a 
large  quantity  of  water  with  the  large  bowel  is  apt  to  increase  the 
tendency  to  diarrhoea.  He  claims,  very  properly,  that  gas,  on  the 
other  hand,  is  a  natural  occupant  of  the  intestinal  canal,  and  whilst 
its  pressure  is  of  the  gentlest,  its  presence  excites  no  unnatural 
peristaltic  action.  He  administers  an  anaesthetic  to  the  point  of 
relaxation  before  the  inflation  is  attempted. 

Dawson^  made  a  number  of  experiments  on  the  cadaver  and 
came  to  the  conclusion  that  when  the  ileo-csecal  valve  is  in  a  normal 
condition,  it  effectually  guards  the  small  intestine  against  the  ingress 
of  fluids  from  below. 

Illoway^  devised  a  force-pump  which  he  strongly  recommends 
for  the  purpose  of  forcing  water  beyond  the  ileo-csecal  valve  in  case 
the  seat  of  an  intestinal  obstruction  is  located  above  that  point.     He 


& 


iQn  Inversion  with    Inflation    in  the  Cure  of    Intussusception.       The 
Lancet,  Jan.  16,  1886. 

2  Lancet  and  Clinic,  Feb.  21,  1885. 

3  American  Journal  of  Medical  Sciences,  Vol.  41,  page  168. 


DISTENTION   OF  COLON    WITH  FLUIDS.  H 

reports  four  cases  of  intestinal  obstruction  treated  by  this  method, 
three  of  which  recovered. 

Battey'  asserts  the  permeability  of  the  entire  alimentary  canal 
by  enema,  and  verifies  his  statement  by  the  recital  of  his  own  clinical 
experience  and  experiments  upon  the  cadaver.  Ziemssen  recom- 
mends inflation  of  the  rectum  for  diagnostic  and  therapeutic  pur- 
poses, and  proceeds  as  follows :  A  rectal  tube  about  six  inches  long 
is  carried  into  the  anus  and  fixed  by  pressing  together  the  nates,  the 
patient  lying  on  the  back.  A  funnel  is  then  connected  with  the 
rectal  tube  by  means  of  rubber  tubing.  For  complete  inflation  of 
the  large  intestine  3  drachms  of  bicarbonate  of  soda,  and  4i  drachms 
of  tartaric  acid  are  separately  dissolved  in  water  and  portions  of 
either  solution  alternately  added.  To  prevent  sudden  over-dis- 
tention  of  the  bowel  it  is  advised  to  add  the  solutions  at  intervals 
of  several  minutes.  A  very  important  use  of  this  method  is  to 
diagnosticate  the  position  of  the  contractions,  strictures,  or  occlu- 
sion of  the  intestine  in  cases  in  which  it  is  desirable  to  operate,  and 
also  as  showing  the  position  of  peritoneal  adhesions.  The  result  of 
his  observations  has  led  him  to  believe  that,  as  a  rule,  the  small 
intestine  is  completely  closed  to  the  entrance  of  substances  from 
the  colon  by  th§  ileo-csecal  valve.  Under  the  influence  of  deep 
chloroform  narcosis,  however,  this  resistance  is  lessened,  and  fluids 
can  be  thrown  into  the  small  intestine. 

Insufflation  of  air  per  rectum  in  the  treatment  of  intestinal 
obstruction  has  been  known  since  the  time  of  Hippocrates.  Gor- 
ham^  was  the  first  to  resort  to  this  method  of  treatment  in  England. 
In  comparing  the  effect  of  enemata  to  air  insufflation,  he  says: 
"But  the  effect  is  totally  different,  when  air  is  used;  its  freedom 
from  all  irritating  qualities,  its  elasticity  and  expansibility  give  it  a 
decided  preference  over  enemata." 

In  my  paper  read  at  the  last  meeting  of  the  International  Med- 
ical Congress^  I  detailed  the  results  of  a  number  of  experiments 
which  I  made  on  dogs,  to  determine  to  my  own  satisfaction  the 
extent  to  which  the  ileo-csecal  valve  is  permeable  to  fluids  forced 


'  Transactions  of  the  American  Medical  Association,  1878. 

2  Observations  on  Intussusception  as  it  occurs  in  Infants.     Guy's  Hospi- 
tal Reports,  Vol.  Ill,  p.  330. 

3  An    Experimental    Contribution  to   Intestinal    Surgery,   with    Special 
Reference  to  the  Treatment  of  Intestinal  Obstruction. 


12  INTESTINAL   SURGERY. 

from  below.  In-  three  cases  where  fluid  was  forced  beyond  the  ileo- 
CEecal  valve,  the  post-mortem  revealed  in  two  of  them,  multiple 
lacerations  of  the  peritoneal  coat  of  the  large  intestine,  while  the 
third  animal  sickened  immediately  after  the  experiment  was  made, 
and  died  from  the  effects  of  the  injuries  inflicted,  eight  days  later. 
These  experiments  combined  with  clinical  experience  leave  no  fur- 
ther doubt  that,  practically,  the  ileo-caecal  valve  is  impermeable  to 
fluids  from  below,  and  that  for  diagnostic  and  therapeutic  purposes 
it  is  unsafe  and  unjustifiable  to  attempt  to  force  fluids  beyond  the 
ileo-c?ecal  valve.  In  two  cases  of  ileocolic  invagination,  in  children 
less  than  two  years  of  age,  I  succeeded  in  reducing  the  bowel  by 
steady  hydrostatic  pressure,  while  the  little  patients  were  under  the 
influence  of  an  anaesthetic  and  held  in  the  inverted  position.  In 
both  instances  the  invagination  had  existed  for  two  or  three  days. 
We  should,  a  priori,  expect  that  air  and  gases,  on  account  of  their 
lesser  weight  and  greater  elasticity  than  water,  could  be  forced  along 
the  intestinal  canal  with  less  force,  and  for  that  reason  alone,  if  for 
no  other,  should  be  preferred  to  water  in  cases  where  it  appears 
desirable  to  distend  the  intestine  below  or  above  the  ileo-csecal  valve 
for  diagnostic  or  therapeutic  purposes.  I  shall,  therefore,  call  your 
attention  briefly  to  : 

3.    Rectal  Insufflation  of  Hydrogen  Gas. 

Hydrogen  gas  is  the  lightest  of  all  known  gases. ^  I  have  demon- 
strated by  my  experiments  that  this  gas  is  non-toxic,  non-irritant 
when  injected  into  the  connective  tissue  and  into  the  large  serous 
cavities,  and  is  rapidly  removed  by  absorption.  Distention  of  the 
entire  gastro-intestinal  canal  with  this  gas  by  rectal  insufflation,  both 
in  man  and  animals,  was  never  followed  by  any  immediate  or  remote 
ill  effects.  Accurate  experiments  to  determine  the  force  requisite  to 
render  the  ileo-csecal  valve  incompetent  by  insufflation  of  air  or  gas, 
had  previously  not  been  made,  and  as  it  is  exceedingly  important  to 
obtain  accurate  information  on  this  subject,  I  made  a  number  of  in- 
flations in  animals  and  man,  estimating  at  the  same  time  the  pressure 
under  which  it  was  made,  either  with  a  mercury  gauge  or  a  man- 
ometer such  as  is  used  by  gas-titters  and  plumbers.       The  gas  was 

Rectal  Insufflation  of  Hydrogen  Gas  an  Infallible  Test  in  the  Diagnosis 
of  Visceral  Injury  of  the  Gastro-intestinal  Canal  in  Penetrating  Wounds  of 
the  Abdomen.     Jour.  Amer.  Med.  Association,  June  23,  30,  1888. 


BECTAL  INSUFFLATION   OF  HYDROGEN   GAS.  13 

collected  in  a  four-gallon  rubbei-  balloon  and  the  inflation  made  by 
compressing  the  balloon.  The  manometer,  or  mercury  gauge  was 
connected  by  means  of  rubber  tubing  with  the  rectal  tube  on  one 
side  and  the  rubber  balloon  on  the  other.  Numerous  experiments 
showed  that  when  the  gas  was  forced  through  the  opening  of  a 
stop-cock,  the  lumen  of  which  was  about  the  size  of  a  knitting- 
needle,  compression  equal  to  two  hundred  pounds  (ninety  kilogr.) 
would  never  register  more  than  two  and  a  half  to  three  pounds  of 
pressure  to  the  square  inch.  In  the  living  subject  the  escape  of  gas 
from  the  rectum  was  prevented  by  an  assistant  pressing  the  margins 
of  the  anus  fi.rmly  against  the  rectal  tube.  A  number  of  experiments 
made  for  the  special  purpose  of  measuring  the  resisting  capacity  of 
the  ileo-csecal  valve  to  the  entrance  of  gas  from  the  csecum  into  the 
ileum,  showed  that  in  a  normal  condition  the  valve  in  a  healthy 
adult  person  is  overcome  by  rectal  inflation  under  a  pressure  vary- 
ing from  one  and  a  half  to  two  and  one-fourth  pounds  (.6  to  1.2 
kilo.).  This  amount  of  pressure  is  not  sufficient  to  injure  any  of 
the  coats  of  a  healihy  intestine  in  any  part  of  its  course.  As  the 
result  of  numerous  observations  on  man  and  animals,  I  can  state  that 
when  the  inflation  is  made  slowly  and  continuously  there  is  less 
danger  of  inflicting  injury  than  when  it  is  done  rapidly  or  inter- 
ruptedly. When  the  patient  is  placed  fully  under  the  influence  of 
an  anaesthetic,  the  ileo-csecal  valve  yields  to  a  lower  pressure  than 
when  the  abdominal  muscles  are  in  a  state  of  rigidity,  as  this  inter- 
feres with  the  requisite  degree  of  distention  of  the  caecum  which  is 
necessary  to  effect  the  separation  of  the  margins  of  the  valve.  A 
rubber  balloon  holding  from  two  to  four  gallons  (ten  to  twenty  litres) 
is  the  simplest,  safest  and  most  efficient  instrument  for  making  rectal 
insufflation  both  for  diagnostic  and  curative  purposes. 

.  Another  series  of  experiments  on  dogs  I  made  in  order  to  deter- 
mine the  degree  of  pressure  which  is  required  to  force  hydrogen  gas 
from  anus  to  mouth,  the  whole  length  of  the  gastro-intestinal  canal. 
In  all  of  the  experiments  the  pressure  fell  rapidly  after  the  ileo- 
csecal  valve  had  been  opened,  but  had  again  to  be  increased  before 
the  gas  reached  the  stomach  and  escaped  through  the  stomach  tube. 
It  usually  required  one-half  to  one  pound  more  pressure  to  force  gas 
through  the  entire  length  of  the  alimentary  canal  than  when  it  had 
to  be  forced  only  through  the  ileo-csecal  valve.  Whenever  it  becomes 
necessary  to  conduct  the  hydrogen  gas  a  considerable  distance  along 


14  INTESTINAL  SURGERY. 

the  intestines,  or  through  the  entire  alimentary  canal,  it  is  exceed- 
ingly important  to  proceed  slowly  with  the  inflation,  as  under  slow 
gradual  distention,  half  a  pound  (.2  kilogr.)  of  pressure  to  the 
square  inch  of  surface  will  accomplish  in  time  a  great  deal  more 
withoiit  doing  harm,  than  four  times  this  amount  of  pressure  if  the 
force  is  applied  quipldy  and  only  for  a  short  time.  In  the  dog,  rectal 
insufflation  of  hydrogen  gas  made  under  a  pressure  of  one-quarter  of 
a  pound,  if  made  very  slowly  and  uninterruptedly,  the  abdominal 
walls  being  completely  relaxed  by  an  anaesthetic,  will  not  only  over- 
come the  resistance  offered  by  the  ileo-csecal  valve,  but  will  prove 
sufficient  to  force  the  gas  through  the  whole  length  of  the  alimentary 
canal. 

Experiments  made  on  different  portions  of  the  gastro- intestinal 
canal  when  in  a  healthy  condition  and  removed  soon  after  death, 
proved  that  laceration  did  not  take  place  under  a  pressure  of  less 
than  eight  pounds,  and  often  it  had  to  be  increased  to  twelve 
pounds.  It  was  found  that  the  resisting  power  of  the  intestinal 
wall  is  nearly  the  same  throughout  the  entire  length  of  the  canal, 
and  in  a  normal  condition  yielded  to  a  diastaltic  force  of  from  eight 
to  twelve  pounds  of  pressure.  When  rupture  took  place,  it  either 
occurred  as  a  longitudinal  laceration  of  the  peritoneum  on  the 
convex  surface  of  the  bowel,  or  as  multiple  ruptures  from  within 
outwards,  at  the  mesenteric  attachment.  The  former  result  followed 
rapid,  and  the  latter  slow,  inflation.  The  superiority  of  hydrogen 
gas  inflation  over  injections  of  liquids  in  the  mechanical  treatment 
of  intestinal  obstruction  is  apparent.  Liquid  injections  cannot 
safely  be  forced  beyond  the  ileo-csecal  valve,  and  even  in  distending 
the  entire  colon  by  liquids  a  great  deal  more  force  is  required  than 
by  insufflation  with  hydrogen  gas.  Insufflation  of  hydrogen  gas  is 
a  valuable  means  of  diagnosis  in  locating  the  seat  of  obstruction 
before  tympanites  has  set  in  and  therefore  best  adapted  at  a  time 
when  most  needed — during  the  early  stage  of  intestinal  obstruction. 
If  the  colon  dilates  uniformly  from  the  sigmoid  flexure  to  the  caecum, 
the  obstruction  must  be  sought  for  higher  up  in  the  intestinal  canal. 
The  passage  of  gas  through  the  ileo-csecal  valve,  rendered  incompe- 
tent by  the  distention  of  the  caecum,  is  always  attended  by  a  char- 
acteristic gurgling  or  blowing  sound  which  is  heard  distinctly  by 
applying  the  ear  or  stethoscope  over  the  ileo-caecal  region.  Not 
infrequently  the  sounds  are  so  loud  and  distinct  that  they  can  be 


RECTAL  INSUFFLATION   OF  HYDROGEN   GAS.  15 

heard  at  a  distance  of  several  feet.  If  the  gas  passes  the  ileo-csecal 
valve  tmder  a  pressure  not  in  excess  of  that  required  to  overcome  it 
in  a  state  of  health,  and,  if  after  inflation  a  thorough  examination  of 
the  ileo-csecal  region  by  inspection,  palpation  and  percussion  reveals 
nothing  abnormal,  the  search  for  the  obstruction  is  continued  by 
inflating  the  small  intestines  slowly  and  making  frequent  examina- 
tions of  the  abdomen  to  ascertain  the  height  to  which  inflation  has 
been  made  and  to  study  the  relative  position  of  the  diiferent 
abdominal  organs.  Inflation  is  also  a  useful  diagnostic  resource  in 
locating  the  obstruction  during  laparotomy  for  intestinal  obstruction. 
The  intestine  below  the  seat  of  obstruction  is  always  empty,  col- 
lapsed and  anaemic  as  compared  with  the  portion  above  the  obstruc- 
tion. When  the  obstruction  is  located  high  up  in  the  intestinal 
canal  and  the  tympanites  is  extensive,  the  empty  portion  of  the 
small  intestines  has,  by  compression,  become  displaced  and  is  often 
not  readily  found.  In  such  cases  the  distention  of  the  bowel 
from  below  will  indicate  to  the  surgeon  at  once  the  location  and 
length  of  the  intestine  below  the  seat  of  obstruction,  and  will 
enable  him  to  search  for  the  obstmction  from  below  upwards. 
The  manipulation  of  the  healthy  intact  portion  of  the  iatestinal 
canal  in  the  search  for  the  obstruction  is  by  far  a  less  hazardous 
procedure  than  the  handling  of  the  distended  portion  above  the 
obstruction,  rendered  paretic,  exceedingly  vascular,  and  much  soft- 
ened by  the  obstruction.  In  cases  where  we  suspect  the  presence  of 
a  perforation,  inflation  with  hydrogen  gas  will  demonstrate  not  only 
its  existence,  but  also  its  location.  Invagination  is  ra,ro  above  the 
ileo-C8ecal  valve,  and  its  location  can  be  determined  by  inflation  with 
hydrogen  gas,  and  if  resorted  to  early,  it  may  prove  the  means  of 
effecting  reduction.  In  ileo-csecal  and  colonic  invagination  slow 
and  persistent  distention  of  the  colon  with  hydrogen  gas,  with  the 
patients  completely  under  the  influence  of  chloroform,  is  the  safest 
and  most  efficient  means  of  effecting  reduction  and  should  always 
be  resorted  to  whenever  these  conditions  are  recognized  or  even 
suspected.  Kectal  inflation  as  ordinarily  practiced,  by  forcing  air 
into  the  rectum  with  bellows,  or  a  Davidson's  syringe  is  not  devoid 
of  danger,  as  the  force  employed  cannot  be  accurately  regulated  or 
estimated. 


16  INTESTINAL   SURGERY. 

Bryant^  lias  collected  twenty  cases  of  invagination  treated  by 
inflation,  in  three  of  which  it  produced  ruptnre  of  the  bowel  below 
the  'invaginated  portion,  while  in  a  fourth  the  child  died  in  collapse 
shortly  after  the  inflation.  He  does  not  look  upon  inflation  as  a 
proper  and  safe  method  of  treatment  in  cases  of  acute  invagination, 
and  in  the  subacute  form,  it  should  only  be  resorted  to  within  the 
first  three  days,  because  later  on  changes  in  the  bowel  are  almost 
certain  to  have  taken  place,  which  would  render  this  measure  fruit- 
less, and  probably  dangerous. 

Knaggs^  reports  the  particulars  of  eight  cases  of  invagination 
where  forcible  distention  of  the  bowel  by  air  or  water  was  the  cause 
of  rupture  or  other  serious  injury  to  the  bowel.  These  cases  show 
that  this  method  of  treatment  is  attended  by  great  risk  in  children 
less  than  one  year  of  age,  as  six  of  the  eight  cases  in  which  harm 
resulted  were  children  less  than  eight  months  old.  In  Symond's 
case  the  abdomen  was  opened  at  once  after  rupture  had  taken  place, 
and  the  rupture  was  sutured.  The  child,  however,  was  too  exhausted 
to  rally  from  the  operation,  but  at  the  necropsy  the  sutured  bowel 
was  able  to  resist  successfully  very  considerable  distention  with  water. 

Greig^  reports  five  cases  of  invagination  treated  by  insufflation 
of  air,  in  four  of  which  it  proved  successful.  In  some  of  the  cases 
the  insufflation  had  to  be  repeated.  Insufflation  of  hydrogen  gas 
from  a  rubber  balloon  is  applicable  in  all  cases  of  subacute  and 
chronic  invagination  and  during  the  early  stage  of  acute  invagina- 
tion, that  is,  before  the  passive  hypergemia  in  the  invaginated  portion 
has  rendered  reduction  by  this  method  impossible.  Should  perfora- 
tion take  place,  the  accident  is  at  once  recognized  by  a  uniform 
distention  of  the  abdomen,  from  the  entrance  of  the  hydrogen  gas 
into  the  peritoneal  cavity,  as  well  as  by  a  sudden  diminution  of 
pressure  readily  felt  by  the  person  who  makes  compression  of  the 
balloon.  The  entrance  of  hydrogen  gas  into  the  peritoneal  cavity 
is  in  itself  a  harmless  occurrence,  as  the  gas  is  non-irritant  and 

^  Harveian  Lectures  on  the  Mode  of  Death  from  Acute  Intestinal  Stran- 
gulation and  Chronic  Intestinal  Obstruction.  British  Medical  Journal, 
1884,  Nov.  22. 

^  Resection  of  an  Irreducible  and  Gangrenous  Intussusception,  etc. 
The  Lancet,  1887,  June  4,  11. 

^On  Insufflation  of  Air  as  a  Remedy  in  Intussusception.  Edinburgh 
Medical  Journal,  October,  1864. 


TUB  AGE   OF   COLON.  17 

perfectly  aseptic.  In  such  cases  the  insufflation  must  be  followed  at 
once  by  abdominal  section  and  the  necessary  operative  treatment  of 
the  invagination. 

4.     Tubage  of  Colon. 

Even  a  fev?'  years  ago  it  was  as  much  a  mooted  point  in  refer- 
ence to  how  far  fluids  could  be  forced  beyond  the  rectum,  as  the 
permeability  of  the  ileo-csecal  valve  is  at  the  present  time. 

Von  Trautvetter'  made  numerous  experiments  on  the  cadaver 
to  determine  how  far  up  into  the  bowel  fluids  could  be  injected 
per  rectum.  He  injected  either  with  an  ordinary  syringe  or  through 
a  rectal  tube.  The  fluid  used  was  a  solution  of  ferrocyanide  of 
potassium,  and  after  the  injection  chloride  of  iron  was  applied  to 
different  parts  of  the  intestine  to  test  for  the  presence  of  the  fluid 
injected.  Ordinary  injections  did  not  pass  beyond  the  lower  portion 
of  the  descending  colon,  while  injections  made  through  a  long 
elastic  tube  reached  the  caecum.  These  experiments  are  only 
alluded  to  as  an  illustration  of  the  ideas  which  were  entertained  in 
reference  to  the  permeability  of  the  colon  to  rectal  injections,  at  the 
time  O'Bierne  first  advocated  the  use  of  the  elastic  rectal  tube  in 
cases  where  it  was  deemed  necessary  to  make  high  injections.  Some 
authors  suggest  the  introduction  of  a  rectal  tube,  in  the  treatment  of 
intestinal  obstruction  as  first  practiced  by  O'Bierne,  and  claim  that 
\vith  it  they  have  reached  the  c?ecum;  but  Treves  assures  us  that 
he  has  made  numerous  experiments  on  the  cadaver  and  has  never 
succeeded  in  passing  it  farther  than  the  sigmoid  flexure. 

Cadge  ^  states  that  even  O'Bierne  never  claimed  that  the  elastic 
rectal  tube  could  be  inserted  farther  than  the  sigmoid  flexure. 
Cadge  made  numerous  attempts  on  the  cadaver  and  was  never 
able  to  reach  the  descending  colon.  In  cases  where  the  tube  was 
introduced  to  a  depth  of  twenty  to  thirty  inches,  he  found  that  the 
tip  of  the  instrument  remained  in  contact  with  the  intestinal  wall; 
and  that  this  portion  of  the  bowel  is  pushed  forward  when  the  end 
of  the  instrument  can  be  felt  through  the  abdominal  wall  at  a 
higher   point.     In   the    administration   of  ordinary  injections,   the 

^  Wie  weit  konnen  Fltissigkeiten  in  den  Darmkanal  per  anum  hinauf  ges- 
pritzt  warden?     Deutsches  Archiv.  f.  Klinische  Medicin,  B.  IV.,  p.  476. 

2  Case   of    Intestinal    Obstruction,    with    Remarks.       British    Medical 

Journal,  1888. 
2 


18  INTESTINAL  SURGERY. 

introduction  of  a  rectal  tube  is  superfluous,  as  in  Hegar's  knee-chest 
position  the  fluid  from  an  ordinary  fountain  syringe  will  follow  the 
course  of  the  colon  and  advance  as  far  as  the  caecum. 

Hegar'  seldom  found  it  necessary  to  elevate  the  funnel  more 
than  one  foot,  a  column  of  water  corresponding  to  this  elevation 
being  found  sufficient  to  force  the  fluid  as  far  as  the  csecum  and  as 
he  believes  sometimes  beyond  the  ileo-csecal  valve.  The  legitimate 
indications  for  tubage  of  the  colon  are  the  following : 

1.  Detection  and  location  of  obstruction  below  the  sigmoid 
flexure. 

2.  To  relieve  gaseous  distention  of  the  colon. 

3.  To  administer  high  nutrient  enemata  in  cases  where  it 
becomes  necessary  .to  maintain  the  strength  of  the  patient  by  this 
method  of  alimentation. 

5.     Manual  Exploration  by  the  Rectum. 

The  introduction  of  the  whole  hand  into  the  rectum  as  a  means 
of  diagnosis  was  devised  and  first  practiced  by  Simon.  This  method 
of  exploration  is  applicable  only  in  the  adult.  Simon  and  his  num- 
erous followers  claim  that  the  hand  can  be  introduced  sufficiently 
far  to  enable  the  surgeon  to  palpate  most  of  the  abdominal  organs. 
Nussbaum  assures  us  that  he  has  felt  more  than  once  the  tip  of 
the  sternum  with  the  hand  employed  in  the  manual  exploration  by 
the  rectum. 

Wagstafl'"  in  his  paper  "On  Intestinal  Obstruction"  places 
great  stress  on  the  importance  of  manual  exploration  by  the  rectum 
as  a  diagnostic  measure,  as  appears  from  one  of  his  conclusions: 
"  That  the  causes  of  obstruction  can  generally  be  determined  by  the 
history  of  present  and  past  illnesses  and  by  thorough  external  and 
internal  examination,  and  that  manual  exploration  by  the  rectum  is 
certainly  the  greatest  advance  in  our  means  of  diagnosis."  The 
glowing  accounts  of  the  value  of  this  method  of  exploration  were 
soon  followed  by  accounts  of  disastrous  consequences  such  as  rupture 
of  the  gut  and  permanent  loss  of  function  of  the  sphincter  muscles. 
Manual  exploration  by  the  rectum  should  only  be  undertaken  by 
surgeons  with  small  slender  hands,   and  the   examination    should 

1  Ueber  Einfiihring  von  FlGssigkeiten  in  Harnblase  und  Darm.  Deutsche 
Klinik,  No.  8, 1873. 

2  St.  Thomas'  Hospital  Reports.     New  Series,  Vol.  IV.,  1873. 


MANUAL  EXPLORATION.— TAXIS  AND  MASSAGE.  19 

always  be  made  with  the  patient  fully  under  the  influence  of  an 
anaesthetic,  and  always  with  the  utmost  care  and  gentleness.  This 
method  of  examination  will  enable  the  surareon  to  ascertain  the 
location  and  nature  of  obstructions  below  the  sigmoid  flexure,  the 
existence  of  volvolus  at  the  sigmoid  flexure,  and  to  determine  the 
presence  of  pathological  conditions  in  the  pelvis  which  might  have 
caused  the  obstruction.  As  a  therapeutic  measure  this  procedure 
can  be  employed  in  the  removal  of  foreign  bodies  or  an  enterolith 
within  reach  of  the  hand,  and  in  the  reduction  of  some  cases  of 
intussusception  where  the  invaginated  portion  of  the  bowel  has 
passed  beyond  the  sigmoid  flexure. 

6.    Taxis  and  Massage. 

Hutchinson  decidedly  opposes  early  operative  interference  in 
cases  of  intestinal  obstruction,  and  expects  little  from  it  in  those 
which  have  been  some  time  in  existence.  He  advocates  what  he 
terms  abdominal  taxis,  under  an  anaesthetic.  By  abdominal  taxis 
he  means  a  thorough  kneading  of  the  abdomen,  with  inversion  of 
the  patient,  shaking  him,  tossing  him  in  a  blanket,  and  a  variety 
of  rough  performances,  the  object  being  to  dislodge  the  bowel,  or 
untwist  the  volvolus.  At  the  same  time  he  advises  large  enemata 
and  cathartics.  If  these  means  do  not  lead  to  the  desired  result,  he 
waits  and  keeps  the  patient  on  a  low  diet,  and  administers  opium 
or  belladonna  internally,  and  subsequently  repeats  the  abdominal 
taxis.  He  reports  a  number  of  cases  successfully  treated  by  this 
method.  It  is  doubtful  if  any  surgeon  at  the  present  time  could 
be  found  who  would  be  willing  to  subject  his  patients  to  such  primi- 
tive treatment  as  advised  by  Hutchinson.  In  most  forms  of 
intestinal  obstruction  such  treatment  is  not  only  unscientific  and 
useless,  but  attended  by  great  risk  to  life,  as  the  violent  movements 
would  not  only  aggravate  the  mechanical  difficulties  which  have 
caused  the  obstruction,  but  might  produce  rupture  of  the  distended 
intestine,  and  could  not  fail  in  causing  exacerbation  of  the  vascular 
disturbances.  Taxis  and  massage,  scientifically  practiced,  have  a 
limited  range  of  application  in  the  treatment  of  intestinal  obstruc- 
tion, as  they  are  applicable  only  to  cases  where  the  obstruction  is 
due  to  the  presence  of  a  foreign  body,  a  faecal  accumulation  or  an 
enterolith,  and  should  only  be  resorted  to  before  these  causes  have 
developed   inflammatory   changes   at   the   seat   of    impaction.      A 


20  INTESTINAL  SURGERY. 

number  of  such  cases  are  on  record  where  this  treatment  proved 
successful. 

Streubel  ^  succeeded,  in  a  boy  eleven  years  of  age  suffering  from 
intestinal  obstruction  due  to  the  impaction  of  a  mass  of  cherry  stones 
above  the  ileo-csecal  valve,  in  removing  the  cause  of  obstruction  by 
submitting  the  swelling  to  gentle  massage  frequently  repeated. 

Marrotte^  gives  an  account  of  a  case  of  acute  intestinal  obstruc- 
tion which  had  lasted  for  some  days  when  fsecal  vomiting  set  in,  and 
in  which  the  usual  internal  treatment  with  opiates  and  chloroform 
afforded  no  relief,  which  was  promptly  cured  by  palpation  of  the 
abdomen  made  for  the  purpose  of  locating  the  seat  of  obstruction. 
The  patient  experienced  a  sensation  at  the  time  as  though  the 
obstruction  had  given  way,  and  soon  afterwards  had  a  number  of 
evacuations  in  which  a  gall-stone  the  size  of  a  walnut  was  found. 
The  author  refers  to  five  cases  of  intestinal  obstruction  caused  by 
the  presence  of  gall-stones,  collected  by  Fauconneau-Dufresne.  One 
of  these  cases  came  under  the  observation  of  Mayo.  In  this  case 
the  gall-stone  was  also  dislodged  by  palpation,  followed  by  cessation 
of  the  symptoms  of  obstruction  and  recovery  of  the  patient.  The 
remaining  four  patients  died.  In  cases  of  fsecal  accumulation  in 
any  portion  of  the  large  intestine  from  the  csecum  to  the  sigmoid 
flexure,  unattended  by  inflammation  and  giving  rise  to  symptoms  of 
obstruction,  and  not  amenable  to  irrigation  of  the  colon,  massage 
and  taxis  should  be  made  while  the  patient  is  under  the  influence 
of  an  anaesthetic,  so  as  to  enable  the  operator  to  break  up  the  mass 
and  to  force  it  onwards  in  the  interior  of  the  bowel  to  a  point  where 
peristaltic  action  is  more  active. 

7.     Puncture  of  Intestine. 

■  Advanced  cases  of  intestinal  obstruction  are  always  attended 
by  great  distention  of  the  bowel  on  the  proximal  side  of  the 
obstruction,  a  condition  which  causes  increased  intra-abdominal 
pressure.  The  tympanitic  distention  of  the  abdomen  may  be  so 
great  as  to  destroy  life  by  the  suspension  of  important  functions 
from  mechanical  pressure.     The  diaphragm  is  pushed  upwards  so 

'Ueber  Erkennung  und  Behandlung  der  inneren  Darmeinklemmung. 
Prager  Vierteljahrsschrift.     B.  XV,  1858. 

2  Einklemmung  eines  Gallen-steines  im  Darme.  Heilung  Durch  Palpa- 
tion dee  Bauches.     Schmidt's  Jahrbiicher.     B.  93,  p.  189. 


PUNCTURE   OF  INTESTINE.  21 

far  that  death  may  ensue  from  asphyxia,  or  the  circulation  is  so  far 
impeded  by  compression  of  the  heart  as  to  cause  death  from  syn- 
cope. Great  distention  of  the  intestines  on  the  proximal  side  of  the 
obstruction  also  aggravates  the  mechanical  difficulties  which  have 
caused  the  obstruction,  as  the  distended  bowel  under  such  circum- 
stances forms  numerous  flexions  which  interfere  with  the  free  pas- 
sage of  its  contents  as  far  as  the  obstruction;  at  the  same  time  the 
distended  coils  may  render  the  bowel  less  peimeable  at  the  seat  of 
obstruction  by  compression.  The  anxiety  with  which  surgeons  look 
upon  extensive  tympanites  following  the  course  of  intestinal  ob- 
struction is  universal,  hence  it  is  only  natural  that  for  a  long  time 
it  has  been  customary  to  make  attempts  in  afPording  relief,  by 
puncturing  the  distended  bowel  through  the  abdominal  wall.  A 
small  trocar  was  usually  employed  for  this  purpose,  but  since  the 
introduction  of  the  hypodermic  needle  and  the  aspirator,  a  hollow 
needle  of  one  of  these  instruments  has  been  used.  Cases  have  been 
reported  where  repeated  punctures  not  only  afPorded  relief,  but 
Anally  led  to  a  permanent  cure.  In  some  instances  the  cannula  of 
a  trocar,  after  puncture,  was  allowed  to  remain  until  a  faecal  fistula 
had  been  established.  An  intestine  distended  to  the  extent  of 
giving  rise  to  distressing  and  dangerous  intra-abdominal  pressure 
is  always  in  a  paretic  condition,  unable  to  expel  its  contents,  and 
whatever  escapes  through  a  needle  or  the  cannula  of  a  trocar  is  ex- 
pelled by  the  contraction  of  the  abdominal  wall.  This  applies  not 
only  to  the  liquid,  but  also  to  the  gaseous  contents.  I  have  repeat- 
edly satisfied  myself  during  operations  on  the  living  subject  aad  in 
animals  where  the  obstruction  was  caused  artificially,  that  mere 
puncture  empties  only  a  limited  space  not  more  than  six  to  eight 
inches  on  each  side  of  the  puncture.  If  aspiration  is  practiced  at 
the  same  time  the  effect  is  doubled;  further  evacuation  is  arrested 
by  flexions  among  the  distended  coils  and  valvular  closure  of  the 
collapsed  segment,  at  the  terminus  of  the  evacuated  area. 

The  recorded  results  of  puncture  of  the  intestine  represent 
largely  only  the  successful  cases,  while  the  numerous  failures  seldom 
find  their  way  into  literature.  Puncture  of  a  healthy  intestine  with 
a  needle  of  moderate  size  is  never  followed  by  extravasation,  as  the 
irritation  incident  to  the  puncture  always  produces  muscular  con- 
tractions which  start  from  the  point  of  puncture  and  at  once  obliterate 
the  canal  made  by  the  needle.     Puncture  of  a  paretic  intestine  is 


22  INTESTINAL  SURGERY. 

always  attended  by  great  risk  of  extravasation,  as  the  muscular  coat 
has  lost  its  tonicity,  and  the  track  of  the  needle  or  trocar  is  slower  in 
closing,  or  remains  permanently  patent.  Numerous  cases  have  been 
reported  where  a  needle  puncture  gave  rise  to  escape  of  faecal  con- 
tents into  the  peritoneal  cavity.  As  the  removal  of  the  tympanites 
is  the  means,  only  in  exceptional  cases,  of  removing  the  cause  of 
obstruction,  and  as  the  puncture  of  a  distended  paretic  intestine  is 
never  devoid  of  risk  of  causing  fpecal  extravasation,  the  legitimate 
indications  for  puncture  of  the  intestine  are  extremely  limited.  If 
employed  at  all,  this  procedure  is  only  applicable  to  cases  where  no 
mechanical  obstruction  is  present,  and  where  the  rapid  distention  of 
the  abdomen,  in  itself,  constitutes  an  imminent  source  of  danger. 
Puncture  should  never  be  resorted  to  with  a  view  of  removing  liquid 
contents ;  its  use  should  be  limited  to  the  evacuation  of  gases.  For 
this  purpose  one  of  the  smaller  needles  of  an  aspirator  should  be 
used.  The  point  of  the  needle  should  be  sharp  so  that  it  can  be 
readily  passed  through  the  intestinal  wall.  The  needle  should 
always  be  thoroughly  disinfected  by  heating  it  in  the  flame  of  an 
alcohol  lamp.  The  point  of  puncture  should  always  be  made  at  the 
most  prominent  point  and  the  instrument  pushed  boldly  forwards 
until  all  resistance  is  overcome.  As  soon  as  gas  escapes,  the  intra- 
abdominal pressure  should  be  increased  by  gentle  and  uniform  com- 
pression of  the  abdominal  walls.  As  soon  as  gas  ceases  to  escape, 
aspiration  should  bo  made  and  continued  as  long  as  anything  can  be 
evacuated,  and  until  the  needle  is  withdrawn,  but  not  at  the  time  it 
is  withdrawn.  Should  it  be  possible  to  ascertain  the  location  and 
direction  of  the  part  of  the  intestine  to  be  punctured,  it  is  advisable 
to  make  the  puncture  obliquely  in  the  long  axis  of  the  bowel  so  as 
to  guard  more  efPectually  against  extravasation. 

8.      Uniform  and  Uninterrupted   Compression  of  the 

Abdomen. 

In  all  cases  of  intestinal  obstruction,  but  more  particularly 
in  the  chronic  form,  uniform  firm  support  of  the  abdomen  affords 
relief  to  the  patient  and  is  one  of  the  best  means  in  preventing  rapid 
distention  of  the  intestine  above  the  seat  of  obstruction.  Fixation 
and  equable  compression  are  resorted  to  in  other  parts  of  the  body 
as  the  best  known  means  in  controlling  muscular  spasm.      It   is 


ENTEROTOMY.  23 

only  reasonable  to  expect  that  the  same  measures  should  prove 
useful  in  retarding,  if  not  in  preventing,  the  violent  peristalsis  in 
cases  of  intestinal  obstruction,  and  especially  in  preventing  over- 
distention  of  the  intestine.  Equable  compression  of  the  abdomen 
should  be  made  before  great  distention  has  occurred.  Uniform 
compression  of  the  abdomen  is  best  secured  by  padding  the  iliac 
regions  with  absorbent  cotton  and  then  enveloping  the  body  from 
the  pubes  to  the  tip  of  the  sternum  with  broad  strips  of  adhesive 
plaster  which  should  be  made  to  overlap  each  other. 

9.      Enterotomy. 

In  1840  N6laton  made  the  first  enterotomy  for  intestinal  ob- 
struction. He  conceived  the  propriety  of  such  an  operation  from 
Mannoury,  who  in  his  thesis  in  1819  first  called  attention  to  the 
formation  of  a  preternatural  anus  in  cases  of  intestinal  obstruction. 
N^laton  taught  that  by  opening  the  abdomen  in  the  right  inguinal 
region  and  seizing  the  first  distended  coil  that  might  present,  the 
surgeon  almost  without  exception  would  establish  the  artificial 
opening  in  the  bowel  near  the  iloo-CJBcal  region.  The  mortality  of 
enterotomy  has  been  nearly  as  great  as  that  of  laparotomy  with 
removal  of  tho  cause  of  obstruction,  and  on  this  score  alone  its 
further  application  should  be  limited  to  exceptional  cases,  cases 
where  a  radical  operation  is  inadmissible  on  accoiint  of  the  nature 
of  the  obstruction  or  the  enfeebled  condition  of  the  patient.  No 
one  who  under  the  pressure  of  circumstances  has  been  forced  to 
establish  a  preternatural  anus,  has  left  his  patient  with  a  feeling  of 
satisfaction,  as  he  must  have  been  sadly  impressed  with  the  fact, 
that,  at  best,  he  has  only  succeeded  in  relieving  the  urgent  symptoms 
of  the  obstruction,  while  he  has  failed  in  removing  the  cause,  and 
consequently  also  in  restoring  the  continuity  of  the  intestinal  canal. 

A  patient  with  an  artificial  anus  is  indeed  an  object  of  pity,  as 
experience  has  sufiiciently  demonstrated  how  difficult  it  is  in  many 
instances  to  close  the  abnormal  opening,  even  after  the  cause  of 
obstruction  is  subsequently  removed  or  corrected  spontaneously, 
without  exposing  him  a  second  time  to  the  risk  of  life  incident  to 
another  abdominal  section.  If  the  causes  which  have  led  to  the 
obstruction  are  of  a  permanent  character,  all  attempts  at  closing 
the  fistulous  opening  will,  of  course,  prove  worse  than  useless,  and 
the  patient  is  condemned  to  suffer  from  this  loathsome  condition  the 


24  INTESTINAL  SURGERY. 

balance  of  his  lifetime,  without  a  hope  of  ultimate  relief.     I  believe 
I  can  safely  make  the  statement  without  fear  of  contradiction,  that 
most  of  these  unfortunate  patients  would  prefer  death  itself  to  such 
a  life  of  misery.       In  performing  enterotomy  the  surgeon  has  no 
means  of  selecting  the  most  desirable  place  in   the  intestine   for 
making  the  opening.     The  only  rule  laid  down  by  the  text-books, 
and  the  only  one  applicable  in  such  a  case,  is  to  secure  in  the  wound 
and  open,  the  first   distended   loop  which   presents  itself.     It  not 
infrequently  happens  that  the  opening  is  made  far  above  the  seat  of 
the  obstruction,  an  occurrence  which  is  attended  by  two  immediate 
sources  of  danger:  1.  Physiological  exclusion  of  a  large  portion  of 
the  intestinal  canal,  which  in  the  event  the  patient  recovers  from  the 
operation  and  the  cause  of  obstruction  remains  permanent,  is  followed 
by  marasmus,  which  in  itself  may  prove  the  cause  of  a  subsequent 
fatal   issue.     2.     The   portion   of   intestine   between   the    artificial 
opening   and   the  seat  of   obstruction   being   the   part  which   has 
suffered   the    most   from   the    effects    of    the    obstitiction   remains 
distended  and  continues  to    exert   the   same   deleterious   effect  as 
•before  the  operation.    Many  able  surgeons,  even  at  the  present  time, 
prefer  enterotomy  to  laparotomy  and  mention  as  principal  arguments 
in  its  favor,  that  it  requires  less  time  in  its  execution  and  can  there- 
fore be  resorted  to  in  patients  where  a  radical  operation  for  this 
reason  alone  would  be  inadmissible;   again,  it  is  claimed  that  the 
intestine  above  the  seat  of  obstruction,  is  not  in  a  condition  for  direct 
operative   measures   which    have    in   view   the   restoration   of   the 
continuity  of  the  intestinal  canal.     It  must,  however,  not  be  for- 
gotten  that   in  quite  a  number  of   cases  the  second  objection  to 
a  radical  operation  does  not  apply,  as  the  removal  of  the  cause  of 
obstruction   is  accomplished   without   interrupting   the    continuity 
of   the   intestinal  canal  and,   as  I  shall  show  further  on,    in   the 
remaining  cases,  where  the  cause  of  obstruction  cannot  be  removed, 
the  continuity  of  the  intestinal  canal  can  be  restored  by  making  an 
intestinal  anastomosis,  which  can  be  done  without  greater  immediate 
or  remote  risk  to  life  than  attends  enterotomy.     As  the  technique  of 
radical  operations  for  intestinal  obstruction  will  be  improved,  the 
indications  for  enterotomy  will  diminish.     As  long  as  the  patient's 
strength  warrants  a  radical  operation,  enterotomy  should  never  be 
performed.     In  patients  so  enfeebled  that  the  administration  of  an 
anaesthetic  would  be  attended  by  imminent  danger  to  life,  an  enter- 


COLOTOMY.  25 

otomy  can  be  made  without  anaesthesia  and  under  such  circumstances 
will  occasionally  save  a  life  which  otherwise  would  be  lost. 

The  operation  is  performed  by  making  an  incision  not  more 
than  two  and  a  half  inches  in  length  in  the  right  iliac  region,  above 
and  parallel  to  the  outer  half  of  Poupart's  ligament.  The  tissues 
should  be  recognized  as  they  are  divided,  without,  however,  using 
a  director  until  the  subperitoneal  fat  is  reached.  This  layer  is 
divided  with  a  blunt  instrument,  and  pushed  aside  when  the  perito- 
neum comes  into  view.  This  membrane  is  seized  with  a  toothed 
forceps  or  lifted  up  with  a  sharp  hook,  and  carefiilly  incised  and 
divided  upon  a  grooved  director.  The  peritoneum  is  united  all 
around  with  the  skin  by  a  continued  suture.  Almost  without  excep- 
tion, a  distended  knuckle  of  intestine,  readily  recognized  by  its  size 
and  color,  presents  itself  in  the  wound,  and  is  united  with  the 
external  wound;  and  after  it  is  securely  fastened,  an  incision  large 
enough  to  admit  the  tip  of  the  index  finger  is  made  in  the  bowel, 
and  the  margins  of  the  visceral  wound  sutured  separately  to  the 
external  wound  by  a  single  suture  on  each  side,  so  as  to  secure 
patency  of  the  opening.  On  incising  the  bowel  the  surgeon  is  often 
disappointed  at  the  small  amount  of  gas  and  fluid  which  escapes, 
and  it  is  frequently  several  hours  before  a  free  escape  takes  place 
and  the  abdominal  distention  begins  to  diminish.  The  escape  of 
intestinal  contents  is  expedited  by  the  introduction  of  a  large-sized 
N^laton's  catheter. 

10.     Colotomy. 

Colotomy  will  always  retain  its  place  in  operative  surgery 
as  a  palliative  and  life-prolonging  procedure  in  the  treatment  of 
carcinomatous  stenosis  of  the  lower  portion  of  the  colon,  and  in 
cases  of  inoperable  carcinoma  of  the  rectum.  The  recent  advances 
in  abdominal  surgery  have  rendered  the  old-fashioned  lumbar  or 
extraperitoneal  operation  obsolete.  The  modern  operation  is  made 
by  opening  the  peritoneal  cavity  in  the  right  or  left  groin,  according 
to  the  indications  which  are  to  be  fulfilled,  and  one  of  its  principal 
objects  is  to  terminate  the  intestinal  canal  at  the  artificial  anus  so 
as  to  provide  absolute  physiological  rest  for  the  portion  of  bowel 
below  it.  The  obvious  disadvantages  of  colotomy,  as  usually  per- 
formed, are  cited  by  Maydl^  as  the  reasons  which  induced  him 

1  Centralblatt  f .  Chirurgie,  No.  24,  1888. 


26  INTESTINAL   SURGERY. 

to  devise  the  operation  which  he  has  described.  He  opens  the 
peritoneal  cavity  by  Littr6's  incision,  and  draws  a  loop  of  intestine 
forward  until  its  mesenteric  attachment  is  on  a  level  with  the  ex- 
ternal incision.  Through  a  slit  in  the  mesentery  close  to  the  gut 
is  inserted  a  hard  rubber  cylinder  wrapped  in  iodoform  gauze.  A 
goose-quill  will  answer  the  same  2:)urpose.  This  device  holds  the 
intestine  in  the  wound  and  prevents  its  return  into  the  abdominal 
cavity.  By  means  of  a  row  of  sutures  placed  on  each  side  of  the 
prolapsed  gut,  including  the  serous  and  muscular  coats,  the  two 
limbs  of  the  flexui'e,  in  so  far  as  they  lie  in  the  abdominal  wound, 
are  stitched  together  beneath  the  rubber  support.  If  the  intestine  is 
to  be  opened  immediately,  it  is  stitched  to  the  parietal  peritoneum 
of  the  abdominal  incision  and  the  latter  protected  by  iodoform  collo- 
dium.  If  the  bowel  is  to  be  incised  later,  the  latter  is  not  stitched 
to  the  peritoneum,  but  surrounded  by  iodoform  gauze  packed  in 
beneath  the  rubber  support,  the  incision  of  the  bowel  being  made 
four  or  six  days  later,  after  the  peritoneal  cavity  has  been  excluded 
by  firm  adhesions.  If  the  artificial  anus  is  made  for  lesions  incap- 
able of  a  subsequent  removal,  a  transverse  opening,  including  one- 
third  of  the  periphery  of  the  bowel,  is  made  by  the  thermo- cautery, 
drainage  tubes  are  inserted  into  the  two  kmiina,  and  the  intestine  is 
carefully  washed  out.  If  the  progress  of  the  case  is  satisfactory  the 
bowel  is  cut  through  completely  in  two  or  three  weeks,  the  rubber 
support  serving  a  useful  purpose  as  a  guide  in  making  this  incision. 
A  few  sutures  will  serve  to  secure  the  cut  end  to  the  skin.  If  the 
direction  of  the  muscular  fibres  has  been  respected  in  making  the 
abdominal  incision,  the  patient  is  provided  with  such  an  eificient 
sphincter  that  a  large  drainage  tube  is  required  to  keep  the  opening 
patulous.  Should  the  artificial  anus  only  be  a  temporary  one,  the 
incision  in  the  intestine  is  made  in  a  longitudinal  direction.  When 
it  has  become  desirable  to  close  the  artificial  opening,  the  rubber 
support  is  removed,  after  which  the  bowel  retracts  and  the  opening 
often  closes  without  any  further  treatment.  If  the  adhesions  are 
too  firm  for  this  they  are  removed  and  the  bowel  is  sutured  and 
returned  into  the  peritoneal  cavity.  Lauenstein  accomplishes  the 
same  object  by  suturing  first  the  peritoneum  to  the  skin,  thus  lining 
the  external  incision  by  peritoneum,  then  drawing  out  a  loop  of 
intestine  and  closing  the  parietal  wound  by  sutures  passing  through 
the  meso-colon  of  the  prolapsed  portion  of  intestine  which  is  thus 


ABDOMINAL  SECTION.  27 

fastened  in  the  abdominal  incision;  next  the  serosa  of  each  limb 
of  the  prolapsed  loop  is  stitched  through  its  entire  circumference  to 
the  parietal  peritoneum. 

An  interesting  discussion  has  arisen  lately  in  Germany  in  regard 
to  a  step  in  the  operation  of  colotomy  which  was  described  by  Knie.* 
So  far  the  operation  has  been  only  done  on  dogs.  It  consists  in 
opening  the  abdomen  transversely  in  the  region  of  the  transverse 
colon,  stitching  the  peritoneum  to  the  edges  of  the  wound,  drawing 
out  the  colon,  making  a  slit  in  the  meso-colon  near  the  gut  with  a 
blunt  instrument  and  closing  the  abdominal  wound  with  two  or 
three  sutures,  which  are  passed  through  the  slit  in  the  meso-colon. 
The  object  of  this  is  to  secure  a  loop  of  the  colon  outside  of  the 
abdominal  cavity.  This  loop  is  to  be  carefully  stitched  at  each  side 
to  the  edge  of  the  (now)  two  abdominal  openings,  after  which  it  is 
to  be  opened  by  an  incision,  or  if  the  symptoms  are  not  urgent,  the 
incision  is  postponed  for  a  feAV  days  until  the  peritoneal  cavity  has 
been  shut  off  by  adhesions.  As  a  general  thing  Lauenstein's  opera- 
tion will  be  found  simplest,  and  should  receive  the  preference  in 
ordinary  cases.  The  modern  operation  of  colotomy  is  indicated  in 
cases  of  congenital  atresia  of  the  rectum  when  the  bowel  cannot  be 
readily  reached  from  below ;  also  in  cases  of  carcinoma  of  the  sig- 
moid flexure  and  the  rectum  not  amenable  to  a  radical  operation. 
Finally,  the  operation  might  become  necessary  in  irreducible  colonic 
invagination  in  which,  for  anatomical  reasons,  resection  or  anasto- 
mosis cannot  be  done. 

II.    Abdominal  Section. 

A  radical  operation  in  the  treatment  of  intestinal  obstruction 
embraces  the  fulfillment  of  two  principal  indications:  1.  The  re- 
moval or  rendering  harmless  of  the  cause  of  obstruction.  2.  The 
immediate  restoration  of  the  continuity  of  the  intestinal  canal.  To 
meet  the  first  indication  the  cause  of  obstruction  must  be  found,  its 
nature  determined,  and  whenever  advisable  or  practicable,  removed, 
a  step  in  the  operation  which  may  be  very  easy,  or  may  demand  a 
most  formidable  and  serious  undertaking,  more  especially  in 
cases  where  the  pathological  conditions  which  have  given  rise  to 
the  obstruction  are  of  such  a  nature  as  to  constitute  in  themselves 
an  imminent  or  remote  source  of  danger,  as,  for  instance,  malignant 


5  Centralblatt  f.  Chirurgie,  May  5,  1888. 


28  INTESTINAL  SURGERY. 

disease  or  gangrene  of  the  bowel  from  constriction.  Abdominal 
section  in  the  treatment  of  intestinal  obstruction  has  so  far  been 
attended  by  a  fearful  mortality,  owing  to  the  fact  that  most  opera- 
tions were  performed  when  the  patients  were  in  collapse,  or  when 
the  parts  involved  in  the  obstruction  had  undergone  advanced  and 
often  irreparable  pathological  changes. 

Ashhurst^  tabulated  fifty- seven  cases  of  laparotomy  for  acute 
intestinal  obstruction  from  other  causes  than  intussusception,  from 
which  it  will  be  seen  that  only  eighteen  terminated  favorably,  so 
that  at  that  time  the  mortality  of  laparotomy  in  cases  of  intestinal 
obstruction  other  than  intussusception,  was  over  68  per  cent.  Most 
of  these  operations  were  performed  without  antiseptic  precautions. 

Schramm  has  collected  one  hundred  and  ninety  cases  of  intesti- 
nal strangulation  treated  by  laparotomy,  including  three  cases 
observed  by  himself  in  the  practice  of  Mikulicz.  He  alludes  to  the 
difficulties  encountered  in  the  diagnosis  of  these  cases  and  pleads  in 
favor  of  early  operative  interference.  Of  this  number  64.2  percent, 
died,  the  mortality  before  the  antiseptic  treatment  of  wounds  being 
73  per  cent.,  and  since  that  time  58  per  cent.  The  cause  of  strangu- 
lation and  mortality  attending  each  kind  may  be  gleaned  from  the 
following  table: 


27 

times, 

Invagination, 

- 

8 

cured, 

19 

died. 

49 

Bands,  or  intestinal  diverticula,    - 

13 

36 

(( 

16 

Adhesions, 

- 

7 

9 

(( 

11 

Reduction  en  tnasse, 

- 

6 

5 

(( 

10 

Torsions, 

- 

1 

9 

(( 

12 

Knotting  of  bowel, 

- 

4 

8 

u 

12 

Internal  strangulation, 

- 

4 

8 

(( 

7 

Foreign  bodies, 

—                          « 

4 

3 

u 

38 

Neoplasms, 

- 

18 

22 

(( 

8 

" 

Unknown  causes,  - 

- 

5 

3 

(i 

Curtis"  has  collected  the  cases  of  intestinal  obstruction  treated 
by  abdominal  section  since  the  year  1873,  consequently  since  the 
antiseptic  treatment  of  wounds  was  introduced.  Table  I.  shows  a 
total  of  328  cases  with  102  recoveries  and  226  deaths,  the  percent- 
age of   mortality  being  68.9 — a  higher  percentage   than   that  of 

1  Amer.  Jour.  Med.  Sciences,  July,  1874. 

2  The  Results  of  Laparotomy  in  Acute  Intestinal  Obstruction.  Annals 
of  Surgery,  May,  1888. 


ABDOMINAL  SECTION.  29 

Schramm's  collection.  Table  III.  shows  that  in  101  cases,  the 
failure  of  the  operation  was  due  directly  to  the  unfavorable  condi- 
tion of  the  patient,  who  was  in  a  dying  condition  in  8  cases.  In 
the  majority  of  the  cases  with  complications,  41  in  all,  the  fatal 
result  was  also  really  due  to  the  condition  of  the  patient,  for  the 
existence  of  peritonitis  or  gangrene  of  the  bowel  at  the  time  of 
operation  shows  that  there  had  been  too  much  delay  in  resorting  to 
operative  measures,  and  most  of  these  cases  died  a  few  hours  after 
operation.  In  28  cases  the  cause  of  obstruction  was  not  found, 
or  could  not  be  removed,  and  in  11  the  reports  are  so  defective 
that  the  cause  of  death  cannot  be  ascertained  from  them.  Of  the 
remaining  45  fatal  cases,  13  died  of  shock,  in  3  cases  the  unusual 
length  of  the  operation  was  probably  the  direct  cause  of  death,  and 
in  17  cases,  sepsis,  probably  due  to  the  operation,  was  the  cause  of 
death.  In  12  cases  the  cause  could  not  be  definitely  learned,  but  as 
death  followed  in  most  of  them  within  24  hours  after  the  operation, 
it  was  probably  shock  and  exhaustion.  In  247  cases  where  the  cause 
of  obstruction  was  removed,  the  mortality  was  only  62.7  per  cent.; 
while  in  74  in  which  it  was  not  done,  the  mortality  was  86.4  per 
cent.  In  41  cases  where  the  obstruction  consisted  of  invagination, 
volvolus,  adhesions,  bands  and  internal  incarceration,  in  which  the 
obstruction  was  not  removed,  not  a  single  one  recovered,  although 
in  16  an  artificial  anus  was  made.  The  greatest  mortality  attended 
cases  where  from  any  cause  suturing  of  the  bowel  was  made,  attain- 
ing the  extreme  point  of  86.6  per  cent,  in  45  cases.  The  necessity 
for  a  short  operation  is  well  shown  by  the  cases  collected  by  Curtis, 
which  give  a  mortality  of  57  per  cent,  in  190  cases  in  which  the 
operative  interference  was  limited  to  relieving  the  obstruction, 
without  wounding  the  bowel,  while  it  rose  to  73  per  cent,  in  15  cases 
in  which  it  became  necessary  to  establish  an  ai-tificial  anus  after  the 
obstruction  had  been  removed,  and  to  83  per  cent,  in  48  cases  in 
which  the  gut  had  to  be  sutured.  In  all  these  cases  the  true  danger 
lay  in  the  length  of  the  operation,  for  death  resulted  from  the 
immediate  effects  of  the  operation  in  most  of  the  cases. 

These  statistics  show  the  value  and  importance  of  early  opera- 
tion, as  sometimes  delay  of  only  a  few  hours  will  bring  complications 
which  not  only  necessitate  more  time  in  their  removal,  but  will  at  the 
same  time  necessitate  a  resection  or  an  anastomosis,  which,  had  the 
operation  been  done  at  an  earlier  date,  might  have  been  obviated. 


30  INTESTINAL  SURGERY. 

The  older  text-books  on  surgery  always  cautioned  the  practitioner  to 
postpone  the  operative  treatment  of  a  strangulated  hernia  for  a 
certain  length  of  time  which  was  often  consumed  in  vain  attempts 
at  reduction,  consequently  the  old  statistics  of  herniotomy  present  a 
high  mortality  when  contrasted  with  recent  operations.  This  striking 
contrast  was  brought  about  not  solely  by  an  improved  technique,  or 
by  the  introdiiction  of  antiseptic  surgery,  but  it  is  largely  owing  to 
the  modern  teaching  that  it  is  dangerous  to  delay  an  operation,  if 
the  strangulation  is  not  relieved  by  gentle  taxis  persisted  in  not  for 
hours  and  days,  but  only  for  fifteen  minutes,  and  at  the  utmost  for 
half  an  hour.  Modern  surgery  recognizes  the  safety  of  an  early 
operation  for  strangulated  hernia,  and  the  results  which  have  been 
obtained  have  demonstrated  the  wisdom  of  the  change  in  practice. 
Vain  and  prolonged  attempts  at  reduction  of  a  strangulated  hernia 
aggravate  the  causes  which  have  produced  the  strangulation,  and 
hasten  the  pathological  changes  in  the  strangulated  intestinal  loop 
which  arise  from  the  strangulation.  If  delay  is  dangerous  in  a  case 
of  strangulated  hernia,  what  can  we  expect  of  a  laparotomy  for 
intestinal  obstruction  when  postponed  until  the  patient  has  been 
exhausted,  or  the  local  conditions  necessitate  complicated  operative 
measures  ?  In  strangulated  hernia  the  destructive  changes  in  the 
constricted  intestinal  loop,  affect  by  continuity  and  contiguity  prima- 
rily only  a  limited  peritioneal  surface,  while  in  intestinal  obstruction 
the  seat  of  obstruction  is  in  direct  communication  with  the  entire 
peritoneal  cavity,  which  becomes  the  seat  of  a  rapidly  fatal,  septic 
inflammation  if  gangrene  or  perforation  have  caused  the  inflam- 
mation. A  recent  intestinal  obstruction  due  to  a  change  of 
visceral  relations,  such  as  flexion,  volvolus,  and  invagination,  if 
subjected  to  operative  treatment  before  conjocutive  pathological 
changes  have  occurred,  would  offer  but'little  difficulty  to  mechanical 
correction  of  the  displacement,  and  as  in  such  cases  the  intestinal 
tube  would  be  in  a  healthy  intact  condition,  the  danger  of  the 
operation  would  not  be  greater  than  that  of  an  ordinary  ovariotomy. 
'  I  think  enough  has  been  said  in  favor  of  early  operation  in  all 
cases  where  the  signs  and  symptoms  indicate  the  existence  of  an 
obstruction  which  does  not  yield  to  milder  measures.  Cases  of 
intestinal  obstruction  are  surgical  lesions  in  every  sense  of  the  word, 
and  should  be  treated  from  the  very  beginning  upon  common  sense 
surgical  principles.     To  temporize  with  such  cases  by  the  adminis- 


ABDOMINAL  SECTION.  31 

tration  of  uncertain  drugs  must  be  looked  upon  as  evidence  of 
ignorance  or  a  relic  of  barbarism.  The  treatment  of  a  case  of 
intestinal  obstruction  upon  the  expectant  plan  until  gangrene  or 
perforation  has  taken  place,  which,  if  submitted  in  time  to  proper 
surgical  treatment,  might  have  been  cured  by  one  stroke  of  the 
scissors  should  be  considered  as  gross  negligence  for  which  the 
modem  aggressive  physician  and  surgeon  can  oflPer  no  justification 
or  apology.  The  future  progress  of  abdominal  surgery  will  conquer 
the  difficulties  which  now  surround  the  diagnosis  and  treatment  of 
intestinal  obstruction.  Experimental  research  and  more  careful  and 
accurate  clinical  observation  will  solve  the  difficult  problems  which 
now  surround  us  in  this  as  yet  unexplored  field  of  surgical  labor. 
Laparotomy  for  intestinal  obstruction  should  not  be  undertaken 
by  every  tyro  in  surgery.  He  who  undertakes  it  should  be  master 
of  the  situation,  familiar  with  every  detail  of  the  technique  of  the 
different  operative  procedures  and  fully  conversant  with  the  manifold 
complications  with  which  he  may  be  confronted.  Every  possible 
contingency  must  be  fully  considered  before  the  abdomen  is  opened, 
as  this  is  an  operation  where  unnecessary  hesitation  and  loss  of  time 
weigh  heavily  in  the  balance  on  the  side  of  failure.  Like  other 
abdominal  operations  laparotomy  cannot  be  mastered  in  the  lecture 
room  or  even  under  the  tuition  of  experienced  surgeons.  Those  who 
expect  to  perform  this  operation  must,  in  the  first  place,  have  a  per- 
fect knowledsre  of  the  structure  and  relations  of  all  the  abdominal 
organs  in  conditions  of  health  and  disease,  and  must  acquire  the 
necessary  operative  skill  on  the  cadaver,  and  then,  what  is  still  more 
important,  should  make  the  more  important  operations  on  the  living 
animal.  It  is  not  necessary  or  even  desirable  that  every  physician 
should  become  a  laparotomist,  but  in  every  section  of  the  country, 
distant  from  the  medical  centers,  some  one  should  interest  himself 
in  this  branch  of  surgery  and  prepare  himself  to  meet  such 
emergencies.  Unlike  a  patient  suffering  from  an  ovarian  tumor, 
a  patient  affected  with  acute  intestinal  obstruction  cannot  be  trans- 
ported great  distances,  and  as  loss  of  time  leads  to  disastrous 
consequences,  it  is  not  always  possible  to  secure  the  services  of  a 
surgeon  versed  in  abdominal  surgery,  from  a  distance.  For  such 
contingencies  I  should  recommend  that  at  least  one  member  of  every 
county  or  district  medical  society  should  familiarize  himself  suffi- 
ciently with  the  details  of  intestinal  surgery  so  that  patients  in  his 


32  INTESTINAL   SURGERY. 

neighborhood  may  reap  the  advantages  of  modern  aggressive  surgery 
at  the  proper  time  and  at  their  own  homes. 

a.     Preparations  for  the  Operation. 

The  most  careful  and  perfect  preparations  should  be  made  for 
the  operation.  The  presence  of  at  least  three  reliable  and  intelligent 
assistants  is  an  absolute  necessity.  As  an  exventration  may  become 
necessary  and  exposure  of  the  intestines  to  a  cool  atmosphere  is  pro- 
ductive of  shock,  an  equable  temperature  of  from  80°  to  85°  Fahr. 
should  be  maintained  in  the  operating  room  from  the  beginning  to 
the  end  of  the  operation.  Opinions  among  operators  may  still  differ 
as  to  the  wisdom  or  even  propriety  of  using  antiseptics  in  a  healthy 
peritoneal  cavity,  but  no  one  at  the  present  day  would  have  the 
courage  to  oppose  the  use  of  strictest  antiseptic  precautions  ia  secur- 
ing an  aseptic  condition  for  everything  that  will  come  in  contact  with 
the  wound  or  the  peritoneal  surfaces.  The  operating  room  must  be 
cleared  of  everything,  except  the  bare  walls  and  windows,  and  the 
whole  of  its  interior  surface  washed  with  a  strong  solution  of  subli- 
mate or  carbolic  acid.  The  table  and  stands  are  disinfected  in  a  simi- 
lar manner.  The  blankets  if  not  perfectly  aseptic  can  be  covered  with 
clean  linen  sheets.  Heat  is  the  most  reliable,  safest  and  cheapest 
sterilizer,  and  can  be  used  for  the  disinfection  of  towels,  napkins, 
instruments  and  wash-basins.  The  operator  imist  satisfy  himself 
of  the  aseptic  nature  of  everything  which  is  used  inside  of  the 
peritoneal  cavity.  The  abdomen  of  the  patient  and  the  operator's 
and  assistants'  hands  are  rendered  aseptic  by  washing  with  potash 
soap  and  warm  water,  and  afterwards  with  a  1-1000  solution  of 
corrosive  sublimate.  The  water  used  for  solutions  and  sponges  is 
sterilized  by  boiling.  For  the  protection  of  prolapsed  intestine  com- 
presses of  aseptic  gauze  or  napkins  are  better  than  sponges,  and  the 
temperature  of  the  parts  is  maintained,  not  by  pouring  warm  water 
on  the  compresses,  but  by  removing  them  and  applying  new  ones 
wrung  out   of  warm  water. 

The  danger  of  using  corrosive  sublimate  solution  within  the 
peritoneal  cavity  is  well  shown  by  Kiimmell's  experience.^  He 
made  nine  laparotomies,  using  for  the  sponges  a  1-5000  solution 
of  sublimate,  and  all  the  patients  recovered  without  an  unpleasant 

*  Ueber  Sublimat-intoxication  bei  Laparatomien.  Centrallblatt  f.  Cbi- 
rurgie,  No.  22,  1886. 


PREPARATIONS  FOR    THE   OPERATION.  33 

gymptom.  Then  he  met  with  two  cases  of  sublimate  intoxication 
in  succession,  having  used  a  solution  of  the  same  strength.  One 
of  the  patients  died  on  the  fourth  day  and  the  post-mortem 
revealed  intestinal  lesions  characteristic  of  acute  mercurial  poison- 
ing. The  other  patient  recovered  after  a  lingering  illness  during 
which  the  symptoms  of  mercurial  intoxication  were  well  marked. 
He  cautions  against  the  use  of  sublimate  in  debilitated,  ansemic 
individuals,  or  in  patients  sufPering  from  renal  disease.  In  cases 
where  the  peritoneal  cavity  is  in  a  healthy  aseptic  condition  the 
use  of  any  of  the  stronger  antiseptics  is  contra-indicated.  For 
the  cases  where  septic  peritonitis,  suppuration,  gangrene  or  perfora- 
tion exists,  a  two  per  cent,  solution  of  boracic  acid,  or  a  saturated 
solution  of  salicylic  acid  (0.3  per  cent.)  should  be  kept  in  readiness 
for  flushing  the  abdominal  cavity.  Bands  of  rubber  or  fine  rubber 
tubing  should  always  be  on  hand,  as  well  as  a  good  assortment  of 
aseptic  silk,  well  prepared  catgut,  glass  drains,  decalcified  perfor- 
ated bone  plates,  and  a  good  assortment  of  needles  and  forceps. 
Stimulants  and  means  to  make  auto-transfusion  must  never  be 
absent,  as  prompt  interference  when  symptoms  of  shock  make  their 
appearance,  may  prove  the  means  of  restoring  the  force  of  the 
circulation  until  reaction  can  be  established  by  other  measures. 

Weir'  suggests  the  administration  of  a  hypodermic  injection 
of  1-100  to  1-80  of  a  grain  of  atropia  and  a  large  rectal  enema  of 
brandy  before  the  anaesthesia,  for  the  purpose  of  increasing  the  force 
of  the  heart's  action.  During  the  operation  the  peripheral  circula- 
tion is  best  kept  up  by  placing  the  patient  on  a  rubber  bed,  filled 
with  hot  water,  and  in  the  absence  of  such  a  contrivance  by  applying 
to  the  extremities  rubber  bags  or  bottles  filled  with  hot  water. 

b.    Anaesthesia. 

A  number  of  American  surgeons  have  recently  expressed  a 
preference  for  chloroform  to  ether  as  an  anaesthetic  in  abdominal 
operations,  as  it  is  less  likely  to  produce  vomiting  before,  during, 
and  after  the  operation.  Another  serious  objection  to  the  use  of 
ether,  especially  in  persons  advanced  in  years,  is  the  frequency  with 
which  bronchitis  is  produced  when  this  anaesthetic  is  exclusively 
used.     The  use  of  chloroform,  however,  is  also  not  free  from  objec- 

I  On  the  Technique  of  the  Operations  for  the  Relief  of  Intestinal  Obstruc-' 
tion.     The  Medical  Record,  Feb.  2,  1888. 

3 


34  INTESTINAL  SURGERY. 

tion.     The  depressing  effect  of  this  anaesthetic  on  the  action  of  the 

heart  is  well  known,  and  as  the  force  of  the  circulation  is  almost 

without  exception  seriously  impaired  in  these  cases,  its  prolonged  use 

might  result  in  dangerous  consequences.    The  best  course  to  pursue 

is  to  follow  the  use  of  chloroform  by  ether.       The  retching  and 

bronchorrhoea  are  prevented  by  placing  the  patient  first  under  the 

influence  of  chloroform  and  the  deleterious  effects  of  the  prolonged 

use  of  this  agent  are  avoided  by  keeping  up  the  narcosis  during  the 

operation  with  ether.     From  the  time  the  first  incision  is  made  until 

the  abdominal  woimd  is  closed,  the  patient  must  be  kept  profoundly 

under  the  influence  of  the  antesthetic,  inasmuch  as  any  interruption 

will  cause  an  unnecessary  delay  in  the  operation  and  may  result 

in  complications  which  are  not  easily  remedied.     Irrigation  of  the 

stomach  should  always  precede  the  administration  of  the  ansesthetic, 

as  evacuation  of  the  stomach  by  preventing  vomiting,  will  guard 

against  the  entrance  of  foreign  material  into  the  larynx  and  trachea, 

which  might  produce  asphyxia  during  the  narcosis,  or  pneumonia 

later. 

c.    Incision. 

■  Differences  of  opinion  still  exist  among  surgeons  as  to  the 
size  and  location  of  the  abdominal  incision.  The  advocates  of 
exventration  argue  in  favor  of  a  long  incision  through  the  median 
line.  Kiimmell  advises  that  it  should  be  carried  from  the  ensiform 
cartilage  to  the  pubis  for  the  purpose  of  affording  free  access  to 
every  part  of  the  abdominal  cavity.  On  the  other  hand,  a  number 
of  distinguished  surgeons,  among  them  Madelung,  Czerny,  and 
Obalinski,  are  in  favor  of  a  small  incision.  Polaillon'  is  strongly 
in  favor  of  a  lateral  incision  in  opening  the  abdomen  for  the  relief 
of  intestinal  obstruction  in  all  cases  where  the  seat  of  obstruction 
can  be  reached  more  directly  by  such  incision.  He  also  claims  that 
in  cases  where  extensive  meteorismus  is  present,  the  distended  intes- 
tines are  more  prone  to  prolapse  and  are  more  difficult  to  return 
through  a  median  than  a  lateral  incision.  He  thinks  that  this  is  due 
to  a  lesser  degree  of  intra-abdominal  pressure  in  the  iliac  than  in  the 
middle  abdominal  region,  and  that  in  the  former  the  muscular  fibres 
keep  the  margins  of  the  wound  in  contact.  He  opens  the  abdomen 
in  the  ilio-inguinal  region  by  an  incision  parallel  with  the  fibres  of  the 
external  oblique  muscle,  and  if  occasion  requires,  this  can  be  made 

1  Gazette  Medicals  de  Paris.     April  25,  1885. 


ABDOMINAL  INCISION.  35 

sufficiently  large  to  permit  exploration  of  the  abdomen  by  the  intro- 
duction of  the  whole  hand.  In  lateral  laparotomy  exploration  is 
less  eas}^,  but  this  operation  is  indicated  in  all  cases  of  localized 
obstruction,  circumscribed  adhesion,  or  when  any  symptoms  render 
it  probable  that  the  obstruction  exists  in  one  or  the  other  side  of 
the  abdominal  cavity.  In  case  a  distinct  swelling,  the  probable 
cause  of  the  obstruction,  can  be  detected  in  the  ileo-caecal  region, 
the  ascending  or  descending  colon,  as  will  probably  be  the  case  in 
ileo-csecal  and  colic  invagination,  volvolus  of  the  sigmoid  flexure, 
tumors  of  the  caecum  and  colon,  the  incision  should  be  made  over 
the  most  prominent  part  of  the  swelling,  as  such  a  course  affords 
the  most  ready  access  to  the  seat  of  obstraction  and  greatly  facili- 
tates the  operative  procedures  which  may  become  necessary.  In 
reference  to  these  points  J.  Greig  Smith  regards  it  a?  only  less  than 
a  surgical  calamity  to  perform  median  laparotomy  for  obstruction  in 
the  colon,  since  in  the  majority  of  cases  it  must,  he  says,  be  supple- 
mented by  a  transverse  or  lumbar  incision. 

In  all  other  forms  of  intestinal  obstruction,  and  in  all  cases 
where  it  is  found  impossible  to  ascertain  the  nature  and  location  of 
the  obstruction,  the  incision  should  be  made  through  the  median 
line.  Not  much  time  should  be  consumed  in  making  the  external 
incision.  With  successive  strokes  of  a  sharp  scalpel  the  tissues  are 
rapidly  divided  until  the  subperitoneal  layer  of  fat  is  reached.  This 
is  picked  up  and  nipped  between  two  toothed  forceps;  when  the 
peritoneum  comes  into  view  it  is  seized  and  divided  in  a  similar 
manner.  The  incision  is  then  enlarged  as  circumstances  may  require 
by  introducing  the  left  index  and  middle  finger  into  the  peritoneal 
cavity  and  dividing  the  tissues  between  them  with  a  blunt-pointed 
bistoury  or  scalpel.  Haemorrhage  is  arrested  as  it  occurs  by  apply- 
ing haemostatic  forceps  to  the  bleeding  points;  this  in  most  in- 
stances obviates  the  application  of  ligatures.  In  reference  to  the 
size  of  the  incision,  this  will  vary  in  accordance  with  the  difficulties 
which  are  encountered  in  locating  the  seat  of  obstruction  and  in 
removing  the  cause  or  causes  which  have  produced  the  occlusion. 
With  few  if  any  exceptions  it  must  be  large  enough  to  admit  the 
introduction  of  the  whole  hand.  As  a  rule  it  may  be  stated  that 
the  ease  in  diagnosis  increases  with  the  size  of  the  incision,  and  the 
danger  which  attends  searching  in  the  dark  for  the  seat  of  obstruc- 
tion more  than  overbalances  the  slight  increase  of  risk  incident  to  a 


36  INTESTINAL  SURGERY. 

large  incision.  Intra-abdominal  manual  exploration  through  a  small 
incision  is,  in  most  instances,  an  unreliable  diagnostic  measure,  as 
the  cause  of  obstruction  may  be  of  such  a  character  as  entirely  to 
elude  such  method  of  examination.  It  is  a  well  known  fact  that  the 
location  of  the  seat  of  obstruction,  even  in  the  post-mortem  room 
after  a  full  abdominal  section,  has  sometimes  been  found  a  difficult 
task.  A  large  incision  shortens  the  operation  by  facilitating  the 
intra-abdominal  examination  and  the  operative  treatment  of  the 
obstruction,  and  the  immediate  risks  of  the  operation  are  diminished 
in  proportion  to  the  shortening  of  the  time  required  in  its  per- 
formance. 

d.    Intra-Abdominal  Examination. 

The  first  and  most  important  object  of  the  external  incision  is 
to  enable  the  surgeon  to  make  a  satisfactory  intra-abdominal  exami- 
nation. Unless  a  positive  diagnosis  has  been  made  beforehand  the 
first  incision  is  an  exploratory  one.  Exploration  of  the  abdomen  for 
the  purpose  of  locating  the  obstruction  and  ascertaining  its  nature  is 
a  more  difficult  procedure  than  in  cases  of  abdominal  tumors,  and  on 
this  account  the  first  or  exploratory  incision  must  be  made  at  least 
large  enough  to  enable  the  surgeon  to  combine  ocular  inspection 
with  manual  exploration. 

Smith'  says:  "The  best  guide  to  the  seat  of  operation  is  not 
manual  exploration,  but  visual  examination,  assisted,  if  necessary,  by 
extrusion  of  bowel." 

The  surgeon  must  bear  in  mind  that  in  nine  out  of  ten  cases  of 
intestinal  obstruction  the  cause  is  located  in  the  lower  portion  of  the 
abdominal  cavity,  below  the  umbilicus,  and  that  in  the  great  major- 
ity of  these  cases  it  will  be  found  either  in  the  right  or  left  inguinal 
region. 

Bryant  lays  down  the  rule  that  in  all  abdominal  operations  for 
intestinal  obstruction,  when  the  seat  of  obstruction  cannot  be  readily 
found,  the  surgeon  should  find  the  caecum,  since  it  is  from  it  that  he 
will  obtain  his  best  guide.  If  this  be  distended,  he  will  at  once 
know  that  the  cause  of  obstruction  is  below;  if  it  be  found  collapsed, 
or  not  tense,  the  obstruction  must  be  higher  up.  The  naked  eye 
appearances  of  the  intestine  that  presents  itself  in  the  incision,  will 
serve  a  useful  purpose  in  deciding  whether  it  belongs  to  the  part 
of  intestine  above  or  below  the  seat  of  obstruction.     In  all  cases  of 

1  The  British  Medical  Journal,  Aug.  29,  1885. 


INTRA-ABDOMINAL   EXAMINATION.  37 

intestinal  obstruction  the  bowel  above  the  seat  of  obstruction  is 
dilated  and  congested,  while  below  the  obstruction  it  is  empty,  pale 
and  contracted.  The  contents  of  the  presenting  loop,  if  distended, 
will  also  indicate  whether  it  is  near  or  distant  from  the  obstruction ; 
if  near,  it  will  probably  contain  fluid  faeces  and  gas;  if  distant,  only 
gas.  If  the  obstruction  is  located  in  the  lower  portion  of  the  small 
intestine,  or  in  any  portion  of  the  colon,  without  exception  a  dis- 
tended loop  above  the  obstruction  presents  itself  in  the  wound. 

Fowler'  has  called  attention  to  the  fact  that  in  all  forms  of 
intestinal  obstruction  the  empty  contracted  portion  of  the  intestine, 
corresponding  to  the  part  below  the  obstruction  is  always  found 
in  the  pelvis,  and  that  it  may  be  most  easily  reached  towards 
the  right  side.  He  explains  this  on  the  supposition  that  during  the 
violent  and  continued  peristalsis  and  gradual  distention  of  the 
bowel  above  the  obstruction,  the  smaller  and  less  active  portion  of 
bowel  below,  after  expelling  its  contents,  is  forced  downwards  into 
the  pelvis,  whilst  the  distended,  and  therefore  specifically  lighter 
portions  rise  to  the  surface.  The  pelvis  also  is  too  small  to  hold 
a  distended  loop.  If  the  seat  of  obstruction  cannot  be  readily 
found  by  manual  exploration  of  the  regions  where  it  occurs  most 
frequently,  two  methods  of  further  examination  present  themselves. 
The  presenting  bowel  is  drawn  forward  into  the  wound  and  sys- 
tematically examined  step  by  step,  as  it  glides  through  the  fingers 
of  the  surgeon  who  replaces  the  loops  as  they  are  examined. 
This  method  of  examination  is  only  safe  and  practicable  where  the 
distention  of  the  intestines  is  moderate,  and  the  intra-abdominal 
pressure  not  excessive,  so  that  loop  after  loop  can  be  drawn  for- 
ward, examined  and  returned  without  injury  to  the  intestine.  If 
this  method  of  examination  is  selected  it  would  be  advisable  to 
secure  the  portion  of  intestine  first  examined  near  the  wound  by 
passing  a  strip  of  gauze  through  its  mese^Iery,  so  that  in  case  the 
obstruction  is  not  found  in  one  direction  the  examination  in  the 
opposite  direction  can  be  made  without  passing  the  portion  already 
examined  again  through  the  operator's  hands.  Mikulicz  attains 
the  same  object  by  an  assistant  holding  the  first  knuckle  that  ap- 
pears against  one  of  the  angles  of  the  wound  while  the  operator 
examines  and  returns  immediately  coil  after  coil  until  the  obstruction 
is  found.     During  the  examination  prolapse  of  the  intestines  is  pre- 

'  The  Lancet,  June  30,  1883. 


38  INTESTINAL   SURGERY. 

vented  by  an  assistant  who  guards  the  opening  with  an  antiseptic 
compress,  and  thus  as  inspection  is  progressing  unnecessary  exposure 
of  the  intestines  is  prevented. 

For  the  purpose  of  avoiding  exventration  and  its  evil  conse- 
quences in  cases  of  intestinal  obstruction  with  great  distention  of  the 
abdomen,  Madelung^  has  recently  described  a  new  method  of  deal- 
ing with  the  distended  intestines.  He  makes  a  comparatively  small 
incision  through  the  median  line  and  brings  the  first  distended 
kniackle  of  intestine  that  presents  itself  into  the  wound  and  by  pass- 
ing two  fixation  ligatures  through  the  mesentery  near  the  gut  and 
making  traction  upon  them,  draws  it  forward  until  both  limbs  of  the 
loop  can  be  ligated  with  a  strip  of  antiseptic  gauze  at  a  point  corre- 
sponding to  the  external  surface  of  the  wound.  The  patient  is  now 
placed  on  his  side  and  the  prolapsed  loop  is  incised  over  the  convex 
surface  and  its  contents  evacuated.  The  gauze  ligature  is  slowly 
loosened  so  as  to  prevent  flooding  of  the  wound  with  intestinal  con- 
tents by  too  forcible  escape  of  the  fluid  contents.  When  the  sponta- 
neous escape  ceases  a  N^laton's  catheter  is  introduced  into  the  incised 
bowel  for  the  purpose  of  facilitating  the  escape  of  intestinal  contents. 
Fifteen  minutes  are  spent  in  efForts  aimed  at  evacuation  of  the  dis- 
tended paretic  intestine,  during  which  time  anaesthesia  is  suspended 
in  order  to  efFect  still  further  evacuation  of  the  bowel  above  the  seat 
of  obstruction  by  the  contraction  of  the  abdominal  muscles.  After 
all  discharge  has  ceased  the  visceral  wound  is  cleansed  and  sutured 
and  the  ligatures  on  each  side  of  the  wound  are  tied  so  as  to  pre- 
vent undue  tension  upon  the  sutures  after  the  gut  has  been  replaced. 
The  ligatures  are  left  hanging  out  of  the  wound  to  serve  as  guides  to 
the  incised  part  of  the  gut  after  the  completion  of  the  intra-  abdomi- 
nal examination.  The  abdominal  incision  is  now  enlarged  dnd  the 
intestine  drawn  forward  and  careful  search  made  for  the  obstruction. 
If  this  is  not  found  the  incised  loop  of  bowel  is  brought  into  the 
wound,  the  sutures  of  the  visceral  wound  and  the  two  ligatures 
removed,  and  an  artificial  anus  established  by  stitching  the  intesti- 
nal wound  to  the  margins  of  the  external  wound,  and  the  portion 
which  is  not  required  for  this  purpose  is  also  sutured. 

While  Madelung's  procedure  cannot  fail  in  facilitating  explo- 
ration of   the  abdomen  by    diminishing   intra-abdominal    pressure 

^  Zur  Frage  der  operativen  Behandlung  der  inneren  Darmeinklemmungen. 
Archiv.  f.  Klin,  Chirurgie,  B,  XXXVI,  p.  283. 


INTRA-ABDOMINAL  EXAMINATION.  39 

it  is  questionable  if  the  room  thus  gained  is  a  sufficient  recompense 
for  the  time  lost  and  the  additional  risks  incident  to  an  intestinal 
wound  in  a  place  where  it  is  not  required.  If  a  laparotomy  is 
decided  upon  in  the  treatment  of  an  intestinal  obstruction,  it  is 
made  for  the  distinct  purpose  of  finding  and  removing  the  obstruc- 
tion; hence  if  the  patient's  strength  is  such  as  to  warrant  this 
treatment  at  all,  the  surgeon  should  not  close  the  abdomen  with 
the  principal  object  of  the  operation  unaccomplished.  How  diflS- 
cult  it  is  to  find  the  obstruction  in  some  cases  is  well  shown  by 
Madehmg,  who  in  several  cases  where  the  seat  of  obstruction 
could  not  be  located  during  life,  requested  the  pathologist  when  he 
made  the  post-mortems  to  locate  the  obstruction  by  introducing  his 
hand  throuarh  an  incision,  allowinor  him  from  ten  to  twentv  minutes 
for  the  exploration ;  in  every  instance  he  failed  to  find  or  locate  the 
obstruction  within  the  specified  time.  Where  the  ordinary  methods 
of  examination  through  an  incision  large  enough  to  permit  the 
introduction  of  the  hand  prove  themselves  inadequate  in  locating 
the  obstruction,  after  a  search  of  from  ten  to  twenty  minutes,  it  is 
useless  and  unwise  to  persist  in  pursuing  the  same  course.  Such 
cases  should  be  dealt  with  by  resorting  to  exventration.  This 
method  of  exploration  was  first  suggested  by  Harber,  in  1872,  and 
practiced  by  KtimmelP  in  1885.  The  large  incision  which  he 
advocates  is  necessarily  followed  by  prolapse  of  the  distended  in- 
testines and  enables  the  surgeon  to  examine  rapidly  and  accui-ately 
every  portion  of  the  intestinal  canal  with  a  view  of  locating  the 
obstruction,  with  little  or  no  risk  of  inflicting  injury  during  the 
examination.  The.  greatest  objection  that  has  been  urged  against 
it  is  that  it  is  sometimes  exceedingly  difficiilt  to  replace  the  in- 
testines even  after  the  cause  of  obstruction  has  been  removed,  as 
the  paretic  intestines  are  slow  in  regaining  their  normal  peristaltic 
action,  and  that  during  the  attempts  at  replacement  the  intestines 
are  often  injured. 

•  The  proper  way  to  effect  replacement  is  to  follow  Kilmmell's 
advice  and  instead  of  making  direct  compression,  to  resort  to  pro- 
tection of  the  intestines  by  covering  the  whole  mass  with  a  warm, 
moist,  aseptic  compress,  the  margins  of  which  are  tucked  in  under 
the  abdominal  incision.    In  this  way  the  bowels  are  protected  against 

^Ueber   Laparotomie   bei  innerer    Darmeinklemmung.      Deutsche   Med. 
Wocheiischrift,  No.  12,  1886. 


40  INTESTINAL  SURGERY. 

the  injurious  effects  of  irregular  direct  pressure  an  are  guided 
back  into  the  abdominal  cavity  as  the  wound  is  closed,  by  tying 
the  sutures,  already  in  place,  from  above  downwards.  If  uniform, 
diffiise,  gentle  pressure  fails  in  replacing  the  intestines,  then  the 
margins  of  the  abdominal  incision  should  be  lifted  with  blunt  hooks, 
an  expedient  which  renders  material  aid  in  effecting  replacement. 
Shoiild  the  obstacles  be  so  great  as  to  frustrate  all  attempts  at 
replacement  it  is  better  to  resort  to  incision  and  evacuation  of  the 
most  distended  portion  of  the  prolapsed  bowel,  which  can  be  done 
with  greater  safety  and  more  marked  effect  than  by  the  plan  devised 
by  Madelung.  This  is  well  illustrated  by  a  case  that  recently  came 
under  my  observation,  which  I  will  report  in  brief. 

The  patient  was  a  woman  forty- eight  years  of  age,  the  mother 
of  eight  children,  the  last  being  an  infant  ten  months  old.  She 
stated  that  she  had  suffered  during  the  last  year  from  constipation, 
but  had  always  been  promptly  relieved  by  cathartics.  Ten  days 
before  her  admission  into  the  Milwaukee  hospital,  April  18,  1888, 
symptoms  of  acute  intestinal  obstruction  appeared,  which  increased 
in  intensity  until  fsecal  vomiting  supervened  the  day  before  she 
came  under  my  observation.  She  had  been  treated  by  high  injec- 
tions and  irrigation  of  the  stomach,  the  former  without  any  effect, 
the  latter  affording  great  relief.  The  patient  was  well  nourished 
and  her  general  appearance  gave  rise  to  no  suspicion  of  malignant 
disease  in  any  of  the  organs.  She  had  passed  nothing  per  viam 
naturalis  since  she  was  taken  ill,  and  the  retching  and  vomiting  were 
persistent.  The  abdomen  was  uniformly  and  enormously  distended; 
upon  the  surface  of  the  abdominal  wall  the  outlines  of  some  dis- 
tended coils  of  intestine  could  be  distinctly  seen.  The  tympan- 
itic distention  of  the  abdomen  interfered  with  respiration,  the 
respiratory  movements  being  shallow  and  rapid,  lips  cyanosed  and 
extremities  cold.  Examination  per  vaginam  and  rectum  revealed 
nothing  as  to  the  seat  and  nature  of  the  obstruction.  Percussion 
and  palpation  of  the  abdomen  yielded  the  same  negative  results. 

Laparotomy  was  performed  under  the  most  careful  antiseptic 
precautions.  The  stomach  was  irrigated  and  chloroform  used  as  an 
anaesthetic.  !  The  operation  was  performed  with  the  patient  upon  a 
rjabber  bed  filled  with  hot  water.  ,  The  first  incision  was  made  half 
way  between  the  umbilicus  and  ^ubes  and  large  enough  to  permit 
the  introduction  of  the  hand.     As  soon  as  the  peritoneal  cavity  was 


INTRA-ABDOMINAL   EXAMINATION.  41 

opened  a  loop  of  small  intestine,  distended  to  three  times  its  natural 
size  and  intensely  congested,  presented  itself.  This  was  pushed 
aside  and  similar  loops  made  their  appearance.  I  now  introduced 
my  hand  and  found  that  the  caecum  and  entire  colon  were  also 
enormously  distended,  which  satisfied  me  that  the  obstruction  must 
be  located  low  down  in  the  colon,  or  the  upper  portion  of  the  rectum ; 
but  the  most  careful  attempts  by  manual  exploration  failed  in  fur- 
nishing any  clue  as  to  the  location  or  nature  of  the  obstruction.  The 
incision  was  enlarged  upwards  an  inch  above  the  umbilicus  and  down- 
wards to  the  pubes  for  the  purpose  of  efPecting  complete  exventra- 
tion.  Two  assistants  caught  the  intestines  as  they  prolapsed  in 
warm,  moist  aseptic  compresses,  and  as  the  abdominal  cavity  was 
nearly  empty  I  could  explore  with  ease  the  sigmoid  flexure,  which  I 
had  reason  to  believe  was  the  seat  of  the  obstruction ;  as  this  part  of 
the  colon  was  only  greatly  distended,  I  had  to  proceed  lower  down 
with  my  exploration  and  finally  found  a  circular  carcinoma  below  the 
sigmoid  flexure  in  the  pelvic  cavity  near  the  junction  of  the  colon  with 
the  rectum. 

As  resection  in  this  locality  was  impossible,  and  as  for  the 
same  anatomical  reasons  an  anastomosis  could  likewise  not  be  made, 
I  was  forced  to  establish  an  artificial  anus.  In  examining  the  colon 
with  the  view  of  the  best  locality  for  making  a  colostomy,  I  found 
that  the  enormous  dilatation  of  this  part  of  the  intestine  had  resulted 
in  such  an  elongation  as  to  force  the  transverse  colon  in  a  downward 
direction  nearly  as  far  as  the  brim  of  the  pelvis.  I  made  an  incision 
in  the  left  inguinal  region  above  Poupart's  ligament,  two  inches  in 
length  and  sutured  the  parietal  peritoneum  to  the  skin.  Into  this 
incision  a  looj)  of  the  displaced  transverse  colon  was  pushed  by  the 
hand  within  the  abdomen  and  fixed  by  a  number  of  sutures.  When 
this  was  done  I  attempted  to  replace  the  intestines,  but  after  trying 
all  the  ordinary  devices  I  had  to  abandon  the  attempt.  The  patient 
was  now  placed  on  her  side,  and  one  of  the  most  distended  loops 
was  grasped,  held  over  a  basin,  and  punctured  with  a  large  trocar, 
while  the  remaining  intestines  remained  covered  with  the  warm  com- 
presses. As  the  escape  of  gas  and  fluid  fa?ces  throiigh  the  cannula 
was  very  slow,  an  incision  an  inch  and  a  half  in  length  was  made  in 
the  gut.  As  the  intestine  did  not  contract,  the  escape  of  contents 
was  very  slow,  and  I  had  to  resort  to  pouring  out  of  the  contents,  as 
it  were,  by  seizing  the  gut  several  feet  above  and  below  the  incision 


42  INTESTINAL   SURGERY. 

and  elevating  it;  a  large  quantity  of  fluid  fseces  "was  literally  poured 
out.  When  no  fuither  evacuation  could  be  effected  the  visceral 
wound  was  closed  by  the  continued  suture,  and  after  thoroughly 
disinfecting  the  loop,  the  bowels  were  returned  without  difficulty. 

The  abdominal  incision  was  closed  in  the  usual  way,  only  that 
I  added  two  tension  sutures  as  a  matter  of  precaution.  After  the 
abdominal  wound  was  closed  and  dressed,  the  colon  that  had  been 
stitched  into  the  inguinal  wound  was  incised  and  the  margins  of 
the  incision  separately  stitched  to  the  sides  of  the  external  wound. 
A  considerable  quantity  of  gas  and  fluid  fseces,  escaped.  The  vomit- 
ing ceased  after  the  operation  and  the  patient  rallied  under  the 
effects  of  stimulants.  The  abdominal  distention  had  diminished 
greatly  the  next  day,  and  disappeared  almost  completely  on  the 
second  day.  The  patient's  general  condition  continued  to  improve 
until  the  tenth  day  after  the  operation,  when  symptoms  of  collapse 
set  in  which  persisted  until  she  died  on  the  following  day.  The 
post  mortem  showed  that  the  median  incision  had  healed  with  the 
exception  of  the  skin,  and  that  the  artificial  anus  had  served  as  a 
perfect  outlet  to  the  intestinal  contents.  Small  intestines  restore^ 
to  nearly  normal  size,  and  incision  healed,  the  fine  silk  suture  being 
completely  imbedded.  The  cause  of  the  recent  diffuse  septic  peri- 
tonitis was  traced  to  perforation  of  a  small  abscess  behind  the 
carcinoma.  The  constriction  caused  by  the  carcinoma  had  reduced 
the  lumen  of  the  bowel  so  much  that  it  was  only  permeable  to  the 
tip  of  the  little  finger. 

I  shall  refer  again  to  the  relation  which  exists  between  chronic 
causes  giving  rise  to  acute  obstruction.  This  case  also  illustrates 
the  importance  of  establishing  the  artificial  anus,  when  such  a 
procedure  cannot  be  avoided,  not  in  the  laparotomy  wound,  but  in 
the  right  or  left  inguinal  region.  When  exventration  is  practiced  it 
is  essential  to  furnish  the  prolapsed  and  dilated  intestine  with  an 
artificial  covering  which  shall  act  as  nearly  as  possible  as  a  sub- 
stitute for  the  abdominal  parietes.  This  is  best  accomplished  with 
warm  compresses  in  the  hands  of  one  or  two  reliable  assistants. 
After  the  surgeon  has  found  the  obstruction  it  becomes  necessary  to 
demonstrate  the  permeability  of  the  remaining  portion  of  the 
intestinal  canal,  as  it  has  happened  that  after  a  successful  removal  of 
an  obstruction,  patients  have  died  because  a  second  obstruction  was 
overlooked.       Of  course   in   such  cases  the    search  for   additional 


INTESTINAL  ANASTOMOSIS.  43 

obstructions  must  be  extended  below  the  obstruction  which  has  been 
found  and  removed.  An  infallible  test  for  ascertaining  the  permea- 
bility of  the  remaining  portion  of  the  intestinal  canal  is  furnished  by 
rectal  insufflation  of  hydrogen  gas.  In  cases  where  after  exventra- 
tion  it  is  not  possible  to  find  the  obstruction  by  examination  of  the 
distended  portion  of  the  intestine,  the  contracted  empty  portion 
below  the  obstruction  can  be  brought  into  sight  by  the  same  means, 
and  a  search  for  the  obstruction  made  from  below  upwards  by 
examining  the  bowel  as  it  becomes  inflated,  until  the  seat  of 
obstruction  is  reached. 

Operative  Treatment  of  the  Obstruction. 
1.     Intestinal  Anastomosis. 

'  What  shall  be  done  if  the  obstruction  cannot  be  found  after  all 
diagnostic  resources  have'  been  exhausted  ?  Shall  we  establish  an 
artificial  anus  and  leave  the  patient  to  the  inevitable  fate  of 
remaining  a  sufferer  from  this  loathsome  condition  the  balance  of  his 
lifetime,  should  he  recover  from  the  operation?  Under  such 
circumstances  the  surgeon  assumes  a  great  responsibility  in  estab- 
lishing an  artificial  anus  high  up  in  the  intestinal  canal,  even  as  far 
as  the  immediate  effects  of  the  operation  are  concerned.  The 
paretic  bowel  below  the  seat  of  the  artificial  outlet,  unable  to  empty 
itself  of  its  contents,  constitutes  an  immediate  and  remote  source  of 
danger,  as  it  leaves  that  portion  of  the  bowel  between  the  new 
opening  and  the  obstruction,  in  the  same  condition  as  before  the 
operation,  and  permanent  exclusion  of  a  considerable  portion  of  the 
intestinal  canal  alone  may  subsequently  destroy  life  by  progressive 
marasmus.  In  such  cases  I  should  advise  the  following  plan  of 
treatment:  The  empty  bowel  below  the  seat  of  obstruction,  if  not 
already  found,  should  be  inflated  with  hydrogen  gas  per  rectum,  and 
the  highest  portion  of  the  inflated  bowel  drawn  forward  into  the 
wound,  and  two  rubber  bands  passed  through  its  mesentery  about 
four  inches  apart  and  held  in  place  by  an  assistant.  The  surgeon 
now  locates  as  near  as  he  can  the  lowest  portion  of  the  bowel  on  the 
obstructed  side,  which  is  also  brought  forward  into  the  wound  and 
similarly  secured.  The  bowel  on  the  proximal  side  is  incised  on  the 
convex  surface  to  the  extent  of  an  inch  and  a  half;  through  this 
incision  the  contents  are  evacuated  as  far  as  possible,  after  which  all 
the  four  rubber  bands  are  tied  and  the  bowel  on  the  distal  side 


44  INTESTINAL   SURGERY. 

incised  in  a  similar  manner.  Into  each  of  these  incisions  a  decalci- 
fied perforated  bone  plate  is  inserted  and,  with  the  lateral  suture 
armed  with  a  round  needle,  the  margin  of  the  wound  on  each  side  is 
transfixed.  After  the  plates  and  sutures  are  in  place  the  loops  are 
thoroughly  disinfected  and  the  serous  surfaces  to  the  extent  of  the 
size  of  the  plates  are  lightly  scarified  with  the  point  of  a  needle, 
when  the  wounds  are  placed  vis-a-vis,  and  the  corresponding  four 
threads  tied  together  with  sufiicient  firmness  to  secure  perfect 
coaptation  of  the  serous  surfaces.  The  sutures  are  cut  short  and  their 
ends  buried  as  deeply  as  possible  by  pushing  them  in  between  the 
approximated  bowels  with  a  director  or  blunt  scissors.  A  few 
superficial  stitches  of  a  continued  suture  will  enhance  the  safety  of 
the  operation.  In  this  manner  an  anastomosis  is  established  with 
the  exclusion  of  probably  only  a  small  portion  of  the  intestinal 
tract. 

After  uniting  two  intestines  by  approximation  plates  in  the 
formation  of  an  intestinal  anastomosis  it  appears  at  first  sight  as 
though  on  the  slightest  distention  of  the  intestines,  leakage  of  gas  or 
fluid  contents  would  take  place  between  the  serous  surfaces.  That 
this  fear  is  unfounded  I  have  satisfactorily  proved  by  a  number  of 
experiments.  The  intestines  of  animals  recently  killed  were  used 
and  an  anastomosis  made  between  the  lower  portion  of  the  ileum 
and  the  colon.  The  colon  was  tied  below  the  new  opening  and  fluid 
forced  into  the  ileum  on  the  proximal  side.  The  pressure  was 
measured  by  a  mercury  gauge.  It  was  found  that  no  leakage  occurred 
under  a  pressure  of  two  pounds  to  the  square  inch,  continued  for 
thirty  seconds.  \  As  even  in  cases  of  great  intestinal  distention  the 
pressiTre  can  never  reach  this  degree,  leakage  from  mechanical  or 
physical  causes  will  never  take  place  from  the  new  opening.  ,  The 
margins  of  the  visceral  wounds  act  like  valves  and  when  the  serous 
surfaces  are  kept  in  contact  by  the  plates,  prevent  the  escape  of  gas 
or  fluids  into  the  peritoneal  cavity.  The  safety  and  practicability  of 
this  operation  I  have  abundantly  demonstrated  by  my  experiments 
on  animals  and  by  a  number  of  operations  on  the  human  subject. 
The  operative  treatment  of  the  obstruction  will  depend  upon  the 
location  and  nature  of  the  obstruction.  If  it  is  decided  not  to 
remove  the  obstruction,  either  on  accoiint  of  its  intrinsic  harmless 
character,  aside  from  its  mechanical  effect,  or  on  account  of  its 
extent,  in  which  case  the  removal  would  be  an  imminent  source  of 


INTESTINAL   ANASTOMOSIS.  45 

danger  to  life,  or  if  after  removal  a  recurrence  in  the  near  future 
appears  inevitable,  an  anastomosis  is  established  between  the  intestine 
above  and  below  the  obstruction  by  lateral  apposition  with  decalci- 
fied perforated  bone  plates.  By  this  operation  the  continuity  of  the 
intestinal  canal  is  restored  with  permanent  exclusion  of  the  seat  of 
obstruction. 

In  cases  of  cicatricial  stenosis  as  a  cause  of  obstruction,  intesti- 
nal anastomosis,  for  instance,  would  be  a  vastly  more  safe  operation 
than    resection    and    circular    enterorrhaphy,    and    would    secure 
equally  well  restoration  of   the  continuity  of   the  intestinal  canal. 
In  cases  of  carcinoma  of  the  intestine  with  extensive  infiltration  of 
the  lymphatic  glands  a  resection  followed  by  circular  enterorrhaphy 
must  always  constitute  a  hazardous  procedure,  and  even  if  it  proved 
successful  an  early  recurrence  of  the  disease  would  be  inevitable. 
Under  such  circumstances  it  is  advisable  to  establish  in  preference 
an  intestinal  anastomosis,  which  will  effectually  exclude  the  cause 
of  obstruction,  alleviate  suffering  and  prolong  life.    The  opponents 
of  laparotomy  in  cases  of  acute  intestinal  obstruction  have  urged 
as  one  of  the  principal  reasons  for  their  opposition  that  the  dilated 
inflamed    intestine    above   the   obstruction   is   not   in   a   condition 
to  undergo  reparative  processes   when   the   operation  demands   a 
solution  of  continuity  in  this  part  of  the  intestinal  tract.     Circular 
enterorrhaphy  under  such  circumstances  is  a  very  dangerous  pro- 
cedure for  two  reasons:     1.     It  becomes  necessary  to  unite  bowel 
ends  of  unequal  size.      2.     The  inflamed  intestine  has  undergone 
textural  changes  illy  adapted  for  suturing,  as  the  sutures  readily  cut 
through  the  softened  tissues.     A  number  of  clinical  observations 
have  satisfied  me  that  the   failures  which  have  attended  circular 
enterorrhaphy  in  such  cases,  are  not  due  to  a  lack  of  healing  capacity 
on  the  part  of  the  inflamed  end  of  the  bowel,  but  to  the  mechanical 
difficulties  which  are  encountered  in  the  approximation  and  retention 
of  the  bowel  ends,  and  the  danger  of  the  cutting  through  or  yielding 
of   the   sutures.      I   believe   on   the   contrary  that   in   case   septic 
peritonitis  does  not  exist,  the  vascularity  of  the  bowel  above  the  seat 
of  obstruction  constitutes  a  favorable  condition  for  rapid  union.     To 
demonstrate  the  correctness  of  this  assertion,  I  made  the  following 
experiments : 

Experiment  1.     Dog,  weight  fourteen  pounds.     The  whole  abdomen  was 
shaved  and  thoroughly  disinfected,  and  while  the  animal  was  under  the  influence 


46  INTESTINAL  SURGERY. 

of  ether  a  small  incision  was  made  in  the  left  iliac  region,  and  a  loop  of  intestine 
drawn  forward  and  ligated  with  a  band  of  iodoform  gauze,  the  ligature  being 
tied  with  sufficient  firmness  to  cause  complete  occlusion,  intestine  returned 
and  wound  sutured.  Seventy-three  hours  later,  the  dog  was  again  etherized 
and  median  laparotomy  performed.  Distended  vascular  loops  of  the  intestine 
came  into  the  wound,  which  were  pushed  aside  and  the  hand  introduced,  which 
being  passed  towards  the  left  inguinal  region  at  once  came  in  contact  with 
the  ligated  portion  which  had  formed  adhesions  to  the  parietal  peritoneum 
and  neighboring  intestinal  loops.  The  adhesions  were  separated  and  the 
ligated  loop  drawn  out  of  the  wound.  Above  the  ligature  the  bowel  was  at 
least  one  and  a  half  times  larger  than  immediately  below  the  seat  of  obstruc- 
tion, very  vascular  and  contained  gas  and  fluid  fasces.  The  degree  of  dilatation 
diminished  from  below  upwards.  The  seat  of  obstruction  was  eight  inches 
above  the  ileo-csecal  valve,  and  the  gauze  ligature  was  covered  with  a  thick 
layer  of  plastic  lymph.  The  obstruction  was  left  and  the  continuity  of  the 
intestinal  canal  restored  by  an  ileo-colostomy  with  perforated  decalcified  bone 
plates.  The  animal,  which  was  not  vigorous  before  the  experiment  was  made, 
appeared  much  prostrated  and  died  twenty-four  hours  after  the  operation. 
The  necropsy  showed  that  the  bowel  above  the  constriction  had  to  a  great 
extent  recovered  its  normal  size  and  color.  The  two  intestines  where  anasto- 
mosis had  been  made  were  firmly  adherent,  the  groove  between  them,  corre- 
sponding to  the  length  of  the  plates,  filled  in  with  plastic  lymph.  New 
opening  permeable;  no  leakage  at  point  of  operation  under  hydrostatic 
pressure.     No  peritonitis. 

Experiment  2.  Dog,  weight  twenty-four  pounds.  Obstruction  produced 
in  a  similar  manner  as  in  preceding  experiment.  Seventy-five  hours  later, 
operative  treatment  of  obstruction  by  laparotomy.  The  seat  of  obstruction 
was  again  readily  found  by  manual  exploration  of  the  abdomen.  Bowel  above 
seat  of  constriction  at  least  twice  the  normal  size  and  highly  congested. 
Peristaltic  action  sluggish,  responding  very  slowly  and  imperfectly  to 
mechanical  irritation.  Gauze  band  buried  under  a  ring  of  plastic  lymph, 
which  bridge-like  united  the  gut  below  and  above  the  constriction.  As  the 
obstruction  was  located  about  the  middle  of  the  ileum,  an  ileo-ileostomy 
by  lateral  apposition  with  decalcified  perforated  bone  plates  was  made,  leav- 
ing the  gauze  band  undisturbed.  The  incision  into  the  bowel  above  the  seat 
of  obstruction  showed  that  all  the  coats  were  thickened  and  softened,  while 
below  the  obstruction,  only  the  mucous  membrane  was  in  a  state  of  catarrhal 
inflammation.  About  eight  inches  of  the  bowel  including  the  seat  of  constric- 
tion were  excluded  by  the  operation.  The  animal  showed  no  signs  of  suffering 
or  illness  after  the  operation,  and  when  killed  after  the  expiration  of  twenty- 
one  days  was  in  excellent  condition.  During  this  time  the  appetite  was  good 
and  faecal  evacuations  normal.  Gauze  band  completely  encapsuled,  and  close 
to  it  an  acute  flexion  of  the  bowel;  excluded  portions  adherent  along  convex 
surface  to  each  other;  bowel  above  constriction  about  one-third  larger  than 
below.     New  opening  admits  the  tips  of  two  fingers. 

Experiinent  3.     Dog,   weight  twenty-eight  pounds.      Laparotomy   seven 
days  after  complete  obstruction  had  been  caused  by  ligation  of  small  intestine 


INTESTINAL  ANASTOMOSIS.  '  47 

•with  gauze  band  through  a  small  wound  in  the  left  inguinaUregion.  Tympan- 
ites moderate.  Obstruction  found  sixteen  inches  above  the  ileo-csecal  region. 
Peristaltic  action  almost  suspended  in  bowel  above  obstruction,  normal  below. 
Intestine  above  the  constriction  dilated  to  twice  its  normal  size,  exceedingly 
vascular,  containing  solid  faecal  masses,  fluid  fjeces  and  gas;  below,  empty, 
contracted  and  ansemic.  Exclusion  of  six  inches  of  the  intestine  at  seat  of 
obstruction  and  restoration  of  continuity  of  intestinal  canal  by  ileo-ileostomy 
with  decalcified  perforated  bone  plates.  After  operation  function  of  intesti- 
nal canal  normal  and  appetite  good.  Killed  eight  days  after  operation;  no 
peritonitis;  adhesion  of  omentum  to  line  of  abdominal  incision;  gauze  band 
completely  covered  by  a  plastic  exudation;  a  number  of  adhesions  between 
adjacent  intestinal  loops.  Point  of  operation  situated  in  the  center  of  a 
horse-shoe  shaped  loop  of  intestine,  which  was  found  to  be  the  excluded  por- 
tion. Intestine  above  obstruction  about  one-fourth  larger  in  size  than  below. 
Excluded  portion  of  bowel  empty.  At  seat  of  anastomosis  a  mass  of  straw 
and  hair  had  accumulated  on  proximal  side.  New  opening  large  enough  to 
admit  two  fingers. 

Experiment  4.  Dog,  weight  thirty-four  pounds.  Complete  obstruction 
of  small  intestines  by  ligation  with  gauze  band  through  a  small  wound  in  the 
left  iliac  region.  Operative  treatment  by  laparotomy  one  hundred  and  twenty 
hours  later.  This  animal  vomited  several  times  shortly  before  the  operation. 
Bowel  at  seat  of  obstruction  adherent  to  adjacent  intestines.  Obstruction 
readily  found  and  brought  into  the  incision.  Intestine  above  constriction 
twice  its  normal  size,  dark  purple  in  color,  tissues  swollen  and  very  much 
softened.  Below  constriction  bowel  empty,  collapsed,  pale,  and  only  the 
mucous  membrane  in  a  state  of  catarrhal  inflammation.  The  dilated  bowel 
contained  gas  and  fluid  faeces.  Peristaltic  action  in  this  part  nearly  sus- 
pended, the  response  to  mechanical  irritation  being  slow  and  imperfect. 
Below  the  obstruction  function  of  bowel  unimpaired.  As  the  occlusion  was 
only  four  inches  above  the  ileo-csecal  valve,  it  was  found  impossible  to  limit 
the  anastomosis  to  the  ileum,  consequently  the  continuity  of  the  bowel  was 
restored  by  an  ileo-colostomy,  uniting  the  ileum  just  above  the  obstruction 
with  the  colon  above  the  caecum,  using  the  perforated  approximation  plates. 
The  gauze  band  was  left  in  situ.  The  animal  showed  no  untoward  symptoms 
after  the  operation,  and  was  killed  twenty-one  days  later.  During  this  time 
appetite  was  good  and  intestinal  functions  normal.  A  number  of  adhesions 
were  found  at  the  site  of  operation  between  adjacent  intestinal. loops.  Gauze 
band  completely  encysted.  Some  crude  material,  as  straw,  hair  and  frag- 
ments of  bone,  was  found  on  the  proximal  side  of  new  opening.  Anastomotic 
opening  large  enough  to  admit  tips  of  two  fingers;  union  between  approxi- 
mated portions  of  intestine  so  complete  that  it  presented  all  around  the 
appearance  as  though  their  peritoneal  surfaces  were  continuous. 

These  experiments  show  conclusively  that  in  acute  obstruction 
even  after  seven  days,  the  bowel  above  the  obstruction  is  capable  of 
undergoing  a  rapid  reparative  process  and  that  adhesive  union  takes 
place  as   early,  if   not  earlier  than  in  operations  upon   a  normal 


48  INTESTINAL   SURGERY. 

intestine.  The  experiments  likewise  prove  the  greater  safety  of 
anastomosis  by  lateral  apposition  with  decalcified  perforated  bone 
plates  than  of  circular  enterorrhaphy  in  restoring  the  continuity  of 
the  intestinal  canal  after  resection.  Anastomosis,  after  resection  for 
intestinal  obstruction,  can  be  made  in  the  same  manner  between  the 
proximal  and  distal  part  after  the  resected  ends  have  been  closed  by 
invagination  and  a  few  stitches  of  the  continued  suture,  as  when  the 
obstruction  is  not  resected  but  excluded. 

In  cases  of  congenital  atresia  of  the  small  intestines,  most  fre- 
quently met  with  in  the  upper  portion,  anastomosis  should  always 
take  the  place  of  circular  resection,  as  the  operation  can  be  done  in 
less  than  twenty  minutes,  an  exceedingly  important  matter  as  far 
as  the  immediate  effects  of  the  operation  is  concerned  in  infants,  at 
the  most  only  a  few  days  old.  In  cases  where  such  a  congenital 
defect  is  suspected  the  abdomen  should  be  opened  in  the  median 
line,  being  careful  not  to  cut  through  the  umbilicus,  when  the  seat 
of  obstruction  can  be  readily  and  rapidly  located  by  inflation  of  the 
stomach  and  rectum  with  hydrogen  gas.  It  is  necessary  to  inflate 
from  both  directions,  as  in  some  cases  the  atresia  is  multiple.  In 
cases  of  cicatricial  stenosis  of  the  pylorus  a  gastro- enterostomy  by 
lateral  apposition  with  approximation  plates  is  a  safer  operation  than 
resection,  or  the  procedures  recommended  by  Loretta  and  Mikulicz, 
while  the  functional  result  is  equally,  if  not  more,  satisfactory.  In 
carcinoma  of  the  pylorus,  where  resection  is  contra-indicated  on 
account  of  the  extent  of  the  disease,  or  its  extension  to  neighboring 
organs,  or  because  glandular  infection  has  taken  place,  suffering  can 
be  diminished  and  life  prolonged  by  making  a  gastro-enterostomy, 
substituting  for  the  tedious  double  suturing  as  advised  by  Wolfler 
the  perforated  approximation  plates.  During  the  last  year  I  made 
four  such  operations  and  with  such  satisfactory  results  as  far  as  the 
operation  was  concerned  that  I  am  induced  to  report  them  in  this 
connection  with  the  hope  that  others  may  give  this  method  of  oper- 
ating a  trial  in  similar  cases.  I  have  made  it  a  rule  that  the  patient 
should  abstain  from  taking  food  by  the  stomach  for  at  least  twenty - 
four  hours  before  the  operation,  and  rely  for  a  few  days,  at  least, 
entirely  upon  rectal  alimentation,  allowing  only  pieces  of  ice  to 
quench  thirst. 

f     The  operations   were   performed   as   follows  :       The   evening 
before  the  operation  the  stomach  was  washed  out  by  the  syphon 


INTESTINAL   ANASTOMOSIS.  49 

tube  and  again  just  before  the  anaesthetic  was  administered.  For 
the  last  irrigation  a  five  per  cent,  solution  of  salicylate  of  soda  was 
used.  In  all  of  tEese  cases  the  incision  was  made  through  the 
median  line  and  extended  from  near  the  ensiform  cartilage  to  the 
umbilicus.  The  opening  in  the  stomach  was  made  parallel  to  the 
long  axis  of  the  organ  and  at  least  an  inch  and  a  half  distant  from 
the  margin  of  the  tumor.  A  continued  suture  of  fine  silk  was  applied 
around  the  whole  circumference  of  the  opening  both  for  the  purpose 
of  arresting  haemorrhage  and  preventing  bulging  of  the  mucous 
membrane.  In  the  intestine  the  opening  was  made  between  two 
rubber  ligatures,  so  as  to  prevent  any  extravasation  of  intestinal 
contents  and  the  margins  of  the  wound  were  sutured  in  a  similar 
manner.  The  opening  in  the  intestine  was  made  first  and  the 
plate  introduced  and  sutures  adjusted  and  the  loop  retained  in  the 
lower  angle  of  the  wound,  covered  by  a  warm  compress.  The  large 
curvature  of  the  stomach  near  the  pyloric  orifice  was  then  drawn 
sufficiently  forward  into  the  wound  to  make  the  incision  and 
introduce  the  plate.  When  everything  was  ready  for  adjustment, 
the  parts  around  the  visceral  wound  were  carefully  disinfected,  dried 
and  the  serous  surface  lightly  scarified  with  an  ordinary  needle 
over  a  surface  corresponding  to  the  size  of  the  plate;  the  new  open- 
ings (wounds)  were  then  brought  opposite  each  other  and  a  fine  silk 
suture,  embracing  only  the  serous  and  muscular  coats,  was  applied 
behind  the  lower  middle-plate-suture  and  tied;  the  middle  lower 
suture  was  now  tied,  while  an  assistant  approximated  the  two  open- 
ings; the  lateral  sutures  were  next  tied,  and  lastly  the  anterior 
middle.  The  sutures  were  all  cut  short  and  ends  buried.  During 
the  tying  of  the  sutures,  it  is  necessary  to  exercise  caution  that  the 
margins  of  the  visceral  wound  are  well  embraced  by  the  plates  all 
around.  As  in  these  cases  the  weight  of  the  intestine  exerts  consid- 
erable tension,  I  have  taken  the  precaution  in  my  two  last  cases  to 
apply  a  superficial  continuous  suture  anteriorly  after  tying  the  four 
sutures,  so  as  to  approximate  the  serous  surfaces  over  the  anterior 
margins  of  the  plates.  The  necessary  preparations  being  made,  with 
good  assistance  the  operation  can  be  finished  in  from  twenty  to 
thirty  minutes.  Neither  shock  nor  peritonitis  was  observed  in  any 
of  the  cases.  Usually  on  the  third  day  small  quantities  of  pepton- 
ized milk  and  beef  tea  were  given  at  short  intervals  and  solid  diet 
during  the  second  week. 


50  INTESTINAL  SURGERY. 

Case  I.  Male,  aged  sixty-five.  Symptoms  of  pyloric  stenosis  for  one 
year.  Emaciated  to  a  skeleton ;  csdema  of  legs ;  unable  to  retain  food  of  any 
kind  for  more  than  a  few  hours.  The  patient  was  so  anaemic  and  prostrated 
that  he  was  only  partially  anaesthetized.  During  the  operation  the  pulse 
became  almost  imperceptible,  and  brandy  had  to  be  administered  subcutane- 
ously,  with  lowering  of  head,  and  hot  applications  externally.  An  hour  after 
the  operation  ^he  pulse  was  stronger  than  before  it  was  commenced.  Rectal 
feeding;  only  slight  rise  in  temperature  on  second  day;  no  pain.  On  the  third 
day  small  quantities  of  liquid  food  by  the  stomach.  The  heart's  action 
gradually  failed  and  the  patient  died  of  marasmus  five  days  after  the  operation. 
The  post-mortem  revealed  that  the  plates  were  still  in  situ,  adhesions  firm  and 
opening  patent.  No  peritonitis.  In  this  case  the  carcinoma  was  circular  and 
limited  to  the  pylorus.  Anastomosis  just  below  the  duodenum.  The  intense 
suffering  had  made  the  patient  desperate,  and  although  the  nature  of  the 
disease  and  the  probable  outcome  of  the  operation  had  been  fully  explained 
to  him,  he  begged  to  have  it  done,  with  a  perfect  understanding  that  at  best 
it  would  afford  only  temporary  relief.  I  am  quite  confident  that  the  operation 
did  not  shorten  his  life. 

Vase  II.  Male,  aged  forty-seven.  Duration  of  disease  eighteen  months; 
obstinate  vomiting;  great  emaciation  and  cBdema  of  legs.  Contour  of  tumor 
could  be  readily  mapped  out  by  percussion  and  palpation.  Tumor  adherent 
to  under  surface  of  liver;  enlargement  of  lymphatic  glands.  In  this  case  the 
anastomosis  was  again  made  just  below  the  duodenum.  No  untoward  symp- 
toms after  operation.  At  the  end  of  the  first  week  solid  food  was  allowed. 
No  vomiting.  At  the  end  of  the  third  week  an  abscess  formed  in  the  upper 
part  of  the  healed  incision,  in  the  contents  of  which  the  plate  ligatures  were 
found.  A  gastric  fistula  formed,  through  which  food  escaped  almost  im- 
mediately after  it  was  swallowed.  This  closed  in  less  than  two  weeks;  after 
which  the  patient  improved  in  strength  and  gained  in  weight.  He  retained 
and  digested  aU  kinds  of  food.  Improvement  continued  so  that  he  was  able 
to  walk  short  distances  and  to  take  lonjj  drives.  At  the  end  of  three  months 
after  the  operation  he  commenced  to  fail  and  died  two  weeks  later  of  progres- 
sive marasmus.     Unfortunately  no  post-mortem  could  be  obtained. 

Case  III.  Male,  aged  thirty-five.  Symptoms  of  pyloric  stenosis  for  six 
months.  Tumor  discovered  four  months  ago,  rapidly  increasing  in  size. 
Considerable  emaciation  and  cachectic  appearance.  Tumor  involves  nearly 
one-third  of  anterior  wall  of  stomach  and  the  entire  pylorus.  Glands  of 
omentum  infiltrated.  The  first  loop  of  intestine  which  came  within  reach  was 
united  with  the  anterior  wall  of  stomach  in  the  usual  manner.  Sutures  of 
abdominal  wound  removed  on  the  eighth  day.  Until  this  time  no  untoward 
symptoms,  although  the  patient  had  taken  liquid  food  for  several  days.  The 
day  following  obstinate  vomiting  occurred;  the  plates,  very  much  softened 
and  greatly  reduced  in  size,  were  ejected.  The  stomach  was  repeatedly 
irrigated,  but  vomiting  continued  until  the  patient  died  three  weeks  after  the 
operation.  Post-mortem:  Abdominal  incision  united  throughout;  omentum, 
stomach  and  intestines  adherent  to  abdominal  incision.     Anastomosis  perfect 


INTESTINAL   ANASTOMOSIS.  •  51 

at  a  point  eight  feet  below  pylorus.  Intestine  between  pylorus  and  artificial 
opening  enormously  distended.  As  the  opening  was  large  enough  to  admit 
two  fingers  it  was  difficult  to  understand  what  had  caused  the  obstruction. 
The  pyloric  orifice  was  large  enough  to  admit  the  tip  of  index  finger.  Fluid 
could  not  be  forced  from  the  stomach  into  the  bowel  below  the  new  opening. 
Injection  through  the  duodenum  was  made  with  the  same  negative  result.  On 
close  examination  it  was  found  that  the  intestine  at  the  point  of  anastomosis, 
probably  on  account  of  the  great  length  of  the  part  between  the  stomach  and 
the  new  opening,  had  become  flexed  at  the  point  where  it  was  attached  to  the 
stomach,  and  the  two  limbs  were  adherent  to  each  other  for  four  inches.  This 
bending  of  the  bowel  had  formed  a  spur,  opposite  to  the  opening  in  the 
stomach  by  the  apex  of  the  concave  side  of  the  bowel,  and  this  spur  acted  like 
a  valve,  closing  the  opening  in  the  distal  part  of  the  bowel  when  water  was 
injected  into  the  stomach  or  duodenum. 

This  case  taught  me  that  it  is  unsafe  to  follow  the  advice  given 
by  Luecke  and  others,  to  seize  the  first  presenting  loop  for  the  anas- 
tomosis, as  by  so  doing,  it  is  possible  to  grasp  a  loop  of  intestine 
which  corresponds  to  the  lower  portion  of  the  small  intestines,  as  in 
this  case.  If  this  is  done  we  not  only  exclude  permanently  too 
great  a  portion  of  the  intestinal  canal  from  the  processes  of  digestion 
and  absorption,  but  a  similarly  unfortunate  mechanical  difficulty  at 
the  new  opening  may  be  created,  as  has  been  described  above. 

Lauenstein  recently  reported  a  case  of  gastro-  enterostomy  where 
the  post-mortem  revealed  that  the  new  opening  was  made  near  the 
ileo-csecal  region.  In  making  a  gastro-enterostomy  it  is  important 
for  the  reasons  just  cited  to  follow  the  advice  of  Hahn  and  search  for 
the  duodenum,  which  when  found  can  be  readily  recognized  by  its 
short  and  fixed  attachments,  and  to  make  the  new  opening  in  the 
upper  part  of  the  jejunum  as  near  as  possible  to  the  duodenum. 

Case  IV.  Male,  aged  forty-three.  Has  complained  of  stomach  difficulties 
for  a  year.  During  the  last  two  months  obstinate  vomiting  an  hour  or  two 
after  meals.  Tumor  as  large  as  a  child's  fist;  movable.  Emaciation  and 
marked  antemia;  glandular  infection  behind  the  stomach.  Anastomosis  made 
just  below  the  duodenum.  Very  little  pain,  and  no  other  symptoms  until  the 
tenth  day,  when  he  vomited  several  times.  Stomach  washed  out  twice,  four 
hours  apart,  and  food  by  the  stomach  discontinued.  No  vomiting  after  this, 
and  after  two  days  a  liquid  diet  ordered.  At  the  end  of  the  second  week  could 
digest  all  kinds  of  solid  food,  which  caused  no  distress.  On  the  thirteenth  day 
fragments  of  both  plates  were  found  in  one  of  the  stools.  Patient  has  gained 
in  flesh,  and  after  four  weeks  presented  a  great  deal  better  appearance  than 
before  the  operation. 

These  cases  have  satisfied  me  that  gastro-enterostomy  in  cases 
of  inoperable  carcinomatous  stenosis  of  the  stomach  is  a  safe  and 


52  INTESTINAL  SURGERY. 

justifiable  operation  and  shonld  be  more  frequently  resorted  to,  as  it 
is  the  only  resource  which  promises  substantial  relief,  prolongs  life 
and  infuses  new  hope  in  a  class  of  patients  otherwise  doomed  to 
certain,  speedy  death. 

2.     Physiological  Exclusion  by  Anastomosis. 

In  some  cases  of  intestinal  obstruction  the  restoration  of  the 
continuity  of  the  intestinal  canal  by  resection  and  circular  enteror- 
rhaphy  would  necessitate  the  removal  of  several  feet  of  the  intestine 
where  the  cause  of  obstruction  in  itself  constitutes  no  intrinsic 
source  of  danger,  and  where  recovery  would  be  more  likely  to  take 
place  by  the  substitution  of  anastomosis  for  resection.  That  resec- 
tion of  a  number  of  feet  of  the  small  intestines  is  not  always  com- 
patible with  health  is  well  illustrated  by  a  case  reported  by  Baum, 
in  which  he  removed  137  cm.  in  a  woman  forty  years  of  age.  The 
patient  was  suffering  from  strangulated  femoral  hernia.  Taxis  was 
only  partially  successful.  On  opening  the  sac  an  offensive  fluid 
escaped,  and  a  portion  of  the  omentum  was  removed.  Peritonitis 
followed  and  a  swelling  formed  in  the  abdomen  above  the  crural 
ring,  which  broke  and  a  fsecal  fistula  formed;  rapid  emaciation 
ensued;  symptoms  of  strangulation  made  a  laparotomy  necessary.  A 
mass  of  intestine  was  found  twisted  into  a  bunch  which  could  not 
be  unravelled,  and  as  it  was  surrounded  by  an  abscess  it  was 
resected  and  the  ends  united  with  sutures.  Patient  recovered  from 
operation  and  improved  for  several  weeks.  Six  months  later  pro- 
gressive marasmus  resulted  in  death.  The  autopsy  revealed  no 
other  cause  of  death  except  marasmus  from  too  extensive  resection. 
In  such  a  case  I  would  propose  that  the  twisted  adherent  intestinal 
coils,  the  cause  of  the  obstruction,  if  they  present  no  evidences  of 
gangrene,  should  be  left  and  permanently  excluded  from  the  f gecal 
circulation  by  making  an  anastomosis  with  approximation  plates 
between  the  bowel  leading  to  and  from  the  obstructing  mass.  A 
case  somewhat  similar  to  Baum's,  but  under  less  favorable  circum- 
stances, came  under  my  care  during  the  last  year  where  this  plan  of 
treatment  was  adopted. 

Strangulated  Hernia;  Resection  of  Gangrenous  Portion;  Additional  Obstruc- 
tion by  a  Mass  of  Adherent  Intestinal  Loox)s;  Restoration  of  Continuity  of 
Intestinal  Canal  by  Anastomosis. — The  patient  was  a  brewer,  thirty  years 
of  age,  who  had  an  inguinal  hernia  for  several  years,  but  never  wore  a  truss. 
On  lifting  a  heavy  weight  the  swelling  became  suddenly  enlarged,  followed  by 


PHYSIOLOGICAL   EXCLUSION  BY  ANASTOMOSIS.  53 

symptoms  of  acute  strangulation.  The  attending  physician  overlooked  the 
hernia  and  treated  the  patient  for  gastritis.  Eight  days  after  the  attack  he 
was  admitted  into  the  Milwaukee  County  Hospital.  At  this  time  symptoms  of 
acute  diffuse  peritonitis  were  well  marked.  Pulse  rapid  and  feeble;  extremities 
cold;  abdomen  tympanitic  and  excessively  tender  on  pressure.  Stercoraceous 
vomiting.  Hernia  as  large  as  a  child's  fist,  skin  covering  it  discolored  and 
oedematous.  It  was  plain  enough  that  gangrene  had  occurred,  and  that  in 
consequence  of  this,  peritonitis  had  developed.  The  patient  was  given  1-120 
of  a  grain  of  atropia  hypodermically  before  chloroform  was  administered. 
On  opening  the  sac  faecal  matter  escaped  and  a  large  mass  of  discolored 
omentum  presented  itself.  The  sac  was  irrigated  with  a  weak  solution  of  sub- 
limate, and  the  omentum  drawn  forward  and  wrapped  in  a  small  compress  of 
gauze.  The  entire  loop  of  intestine  was  gangrenous  and  perforated  on  the 
convex  surface  at  its  highest  point.  The  parts  were  again  irrigated  before 
the  inguinal  canal  was  laid  open  by  incision.  The  omentum  was  now  drawn 
downward  until  a  healthy  portion  was  reached,  when  it  was  ligated  in  several 
parts  and  cut  off.  The  intestine  was  separated  from  its  attachments  to  the 
inguinal  canal  and  the  gangrenous  part,  about  eight  inches  in  length,  excised, 
after  having  previously  guarded  against  ftecal  extravasation  by  applying  a 
rubber  ligature  on  each  side.  Examination  of  the  abdominal  cavity  at  this 
time  showed  recent  peritonitis. 

In  drawing  down  the  proximal  end  of  the  gut  it  was  found  that  it  was  but 
little  distended,  hence  search  was  made  for  an  additional  obstruction  higher 
up,  which  was  found  in  the  shape  of  a  mass  of  intestinal  coils  twisted  in  every 
conceivable  shape  and  so  firmly  adherent  that  all  attempts  at  unravelling  had 
to  be  abandoned.  The  intestine  above  this  point  was  enormously  distended, 
showing  that  the  bunch  of  adherent  intestines  had  caused  a  second  obstruc- 
tion. Excision  of  three  to  four  feet  of  intestines,  under  these  circumstances, 
was  not  to  be  thought  of,  as  the  patient  would  certainly  have  died  on  the 
table.  Should  I  leave  the  cause  of  obstruction  and  establish  an  artificial  anus 
on  the  proximal  side?  I  decided  to  leave  the  obstruction  and  establish  a 
communication  between  the  intestine  on  the  distal  and  proximal  sides  of  the 
obstruction.  Both  resected  ends  were  closed  by  invagination  and  a  few 
stitches  of  the  continued  suture.  By  lateral  apposition  with  decalcified  per- 
forated bone  plates  an  anastomosis  was  established  between  the  distal 
collapsed  end  and  the  dilated  bowel  on  the  proximal  side  of  the  obstruction. 
Before  the  approximation  sutures  were  tied,  the  intestinal  contents  were 
evacuated  as  far  as  possible.  The  whole  peritoneal  cavity  was  flushed  with 
sterilized  water,  carefully  dried,  drained,  and  the  wound  sutured.  The  toilette 
of  the  peritoneum  was  made  with  a  sponge  wrung  out  of  a  1-2000  solution  of 
sublimate.  The  hernial  sac  was  excised  and  the  stump  fastened  in  the  inguinal 
canal  by  the  deep  sutures  used  in  closing  the  external  wound.  Duration  of 
operation  less  than  an  hour.  The  patient  rallied  from  the  operation,  but 
succumbed  to  the  peritonitis  at  the  end  of  twenty  four  hours.  Post-mortem: 
On  removing  the  sutures  the  sac  walls  were  found  agglutinated  by  plastic 
lymph.   Drainage  tube  surrounded  by  a  thick  layer  of  plastic  lymph,  and  coils 


54  INTESTINAL   SURGERY. 

of  intestine  which  completely  shut  out  the  abdominal  cavity.  Only  about 
half  of  the  omentum  remained.  The  part  of  intestine  where  anastomosis  was 
made  was  found  in  the  pelvis  lyingj  against  the  concave  surface  of  the  sacrum, 
surrounded  by  numerous  recent  adhesions.  The  new  opening  was  twelve 
inches  above  the  ileo-csecal  valve;  adhesion  between  the  serous  surfaces,  held 
in  approximation  by  the  plates,  was  sufficiently  firm  to  prevent  leakage  under 
strong  hydrostatic  pressure.     Opening  patent. 

My  experiments  on  animals  related  in  th©  paper  previously- 
referred  to,  have  demonstrated  that  physiological  exclusion  of  a  cer- 
tain portion  of  the  intestinal  tract  is  a  less  dangerous  operation  than 
excision.  The  appearances  of  the  specimens  also  tend  to  prove  that 
as  long  as  any  of  the  contents  of  the  intestines  reach  the  excluded 
portion,  the  peristaltic  or  anti-peristaltic  action  in  that  part  is  effect- 
ive in  forcing  it  back  into  the  active  current  of  the  faecal  circulation." 
If  the  excluded  portion  again  becomes  permeable  it  resumes  its 
physiological  ftmction  and  again  takes  an  active  part  in  the  processes 
of  digestion  and  absorption ;  if  the  obstruction  remains  permanent  it 
undergoes  progressive  atrophic  changes. 

3.  Lapaeo-Enterotomy. 

Incision  of  the  bowel  for  the  removal  of  obstruction  during 
laparotomy  is  indicated  when  the  obstruction  is  due  to  the  presence 
of  a  foreign  body,  a  concretion,  an  enterolith,  or  a  pedunculated 
benign  polypoid  tumor.  In  the  removal  of  a  foreign  body,  a  con- 
cretion, or  an  enterolith,  not  amenable  to  removal  by  submural 
crushing,  or  fragmentation  with  a  needle,  the  incision  for  extraction 
should  not  be  made  over  the  seat  of  impaction,  as  this  part  of  the 
intestine  has  undergone  changes  unfavorable  to  the  satisfactory 
healing  of  the  visceral  wound.  It  is  much  better  in  such  cases  to 
make  the  incision  in  a  healthy  part  of  the  intestine  an  inch  or  two 
below  the  impaction,  and  then  crush  the  foreign  body  by  instruments 
introduced  through  the  incision.  The  removal  of  a  non-malignant 
pedunculated  polypoid  tumor  is  to  be  accomplished  by  making  an 
incision  on  the  convex  surface  of  the  bowel  large  enough  to  admit  of 
dragging  of  the  tumor  through  it,  after  which  the  base  of  the 
pedicle  is  transfixed  by  a  double  ligature  and  tied,  the  tumor  cut  off, 
and  the  wound  closed  in  the  usual  manner. 

4.  Enteeectomy. 

Enterectomy  is  indicated  when  the  obstruction  is  due  to  a 
malignant  tumor  if  it  is  possible  to  remove  the  disease  completely, 


ENTERECTOMY. 


55 


also  for  the  removal  of  benign  tumors  which  cannot  be  excised  by 
enterotomy,  and  in  all  cases  where  gangrene  has  been  caused  by 
constriction,  compression  or  over-distention.  Carcinomatous  stenggis 
is  met  with  most  frequently  in  the  la^ige  int.fistine,  while  the  causes 
which  result  in  gangrene  are  most  common  above  the  ileg-csecal 
valve.  For  malignant  disease  resection  should  be  done  if  the  entire 
tumor  and  all  infected  glands  can  be  removed  completely  and  with 
safety.  Even  if,  on  account  of  loss  of  substance,  circular  enteror- 
rhaphy  cannot  be  made  in  such  cases,  the  continuity  of  the  in- 
testinal canal  can  be  restored  by  lateral  implantation,  or  by  lateral 
apposition  with  decalcified  bone  discs.  Immediate  circular  enteror- 
rhaphy  after  resection  for  intestinal  obstruction  has  always  been 
attended  by  a  great  mortality,  for  reasons  mentioned  elsewhere.  In 
a  series  of  thirty-five  resections  of  the  large  intestine,  which  Weir 
collected,  when  symptoms  of  obstruction  indicated  the  operation,  th^ 
mortality  amounted  to  one  hundred  per  cent.  Reichel'  has  also 
shown  that  resection  of  the  small  intestines  for  conditions  giving 
rise  to  obstruction,  gave  a  mortality  of  75  per  cent.,  whereas  in 
secondary  resection  for  an  artificial  anus,  the  mortality  is  reduced  to 
37  per  cent.,  a  statement  which  is  supported  by  Makins^  in  his 
report  of  fifteen  deaths  in  thirty-nine  resections  for  artificial  anus. 
If  after  the  resection  is  made,  a  primary  circular  enterorrhaphy  is 
not  made,  Hahn  recommends,  so  as  to  preserve  the  advantages  of  a 
clean  wound  and  yet  to  allow  the  escape  of  faeces,  that  the  intestine 
should  be  closed  tightly  around  a  rubber  tube,  which  is  left  project- 
ing some  distance  for  this  purpose. 

In  the  removal  of  a  tumor  of  the  caecum  with  partial  resection 
of  the  intestinal  wall,  it  may  be  advisable  to  follow  the  example  of 
Porter'*  in  restoring  the  continuity  of  the  intestinal  canal  by  suturing. 
In  his  case  a  part  of  the  circumference  of  the  caecum  including  a 
portion  of  the  ileo-csecal  valve  was  resected  for  the  cure  of  a  faecal 
fistula.  The  wotmd  was  closed  by  slitting  up  a  portion  of  the  ileum 
from  the  seat  of  resection  and  uniting  the  margins  of  this  wound 


*  Kasuistische  Beitrage  zur  cirkularen  Darmresektion  und  Darmnaht, 
Deutsche  Zeitschrift  f.  Chirurgie,  B.  XIX,  Heft  2.  u.  3.      • 

2  Med.  Chir.  Transactions,  vol.  LXVI. 

^Excision  of  a  Portion  of  Intestine,  including  Part  of  the  Ileo-Caecal 
Valve,  for  the  Cure  of  Faecal  Fistula  in  Right  Groin.  Bost.  Med.  &  Surg.  Journal, 
May  15,  1884. 


56  INTESTINAL   SURGERY. 

with  the  resected  surface  of  the  csecum.  The  patient  recovered. 
In  cases  where  the  lumina  do  not  correspond  it  is  advisable  to  follow 
the  suggestion  first  made  by  Wehr  in  performing  pylorectomy, 
viz. :  to  cut  the  end  of  the  narrower  part  of  the  bowel  not  trans- 
versely, but  sufficiently  oblique  so  that  the  circumference  of  the 
oblong  opening  will  correspond  to  the  lumen  of  the  larger  end  of 
the  bowel.  The  obliquity  should  always  be  made  at  the  expense 
of  the  convex  portion  of  the  bowel,  so  as  to  interfere  as  little 
as  possible  with  the  vascular  supply  from  the  mesenteric  side. 
Madelung  in  resecting  the  bowel  makes  his  incisions  somewhat 
obliquely  in  the  same  direction,  for  the  purpose  of  guarding  more 
efPectively  against  gangrene  on  the  convex  side  of  the  bowel  after 
circular  enterorrhaphy.  In  such  extensive  resection  of  the  colon 
where  the  possibility  of  circular  suturing  is  precluded  on  account 
of  the  impossibility  of  approximating  the  cut  ends,  an  artificial 
anus  should  never  be  established,  as  no  subsequent  treatment  could 
restore  the  continuity  of  the  intestinal  canal.  Two  such  cases  were 
recently  reported  by  Hahn. 

It  is  possible  that,  in  the  future,  experimental  research  will 
prove  'the  practicability  of  restoring  such  defects  by  a  plastic  opera- 
tion, consisting  of  transplantation  of  a  corresponding  portion  of 
the  small  intestines  between  the  separated  ends,  a  procedure  which 
would  necessitate  circular  suturing  at  three  different  points.  Until 
it  has  been  shown  that  some  such  plan  is  feasible,  the  surgeon 
must  content  himself  with  establishing  an  anastomosis  between 
the  i^roximal  and  distal  end  by  lateral  apposition  with  decalcified 
perforated  bone  plates.  -  The  latter  procedure  offers  all  the  advan- 
tages to  be  derived  from  approximation  and  keeping  in  uninter- 
rupted coaptation  a  large  serous  surface,  with  immobilization  of 
the  parts  it  is  intended  to  unite  during  the  process  of  repair.  In 
circumscribed  gangrene,  due  to  decubitus  and  involving  not  more 
than  one-half  of  the  circumference  of  the  bowel,  affecting  its  lateral 
or  convex  surfaces,  such  as  is  caused  by  constriction  by  a  narrow 
band,  resection  is  not  necessary.  After  the  constriction  has  been 
removed,  the  gangrenous  spot  is  turned  inwards  and  is  covered 
by  suturing  the  adjacent  healthy  margins  of  the  bowel  over  it.  The 
serous  surfaces  unite  rapidly,  so  that  perforation  during  the  sepa- 
ration of  the  gangrenous  part  is  prevented  by  union  of  the  serous 
surfaces  over  it.      When  a  whole  loop  or  number  of  loops  of  the 


DIRECT   TREATMENT  IN  STRANGULATION.  57 

intestine  present  evidences  of  gangrene  from  constriction,  the 
indications  for  resection  are  clear  as  affording  the  only  possible 
chance  of  preventing  death  from  sepsis  or  perforation.  Unfortu- 
nately in  such  cases  septic  peritonitis  has  usually  set  in  before  the 
operation  is  performed,  and  it  becomes  necessary  after  the  resection 
has  been  made  and  the  continuity  of  the  intestinal  canal  restored  by 
approximation  plates,  to  treat  the  peritonitis  by  flushing  the  abdom- 
inal cavity  with  sterilized  water,  and  disinfection  with  some  mild 
antiseptic,  as  a  one-third  per  cent,  solution  of  saHcylic  acid,  as 
advised  by  Mikulicz.     Drainage  in  such  cases  is  a  necessity. 

5.     Direct  Treatment  of  Obstkuction  in  Strangulation  by  a  Band 
OR  Diverticulum,  Flexion,  or  Adhesion  of  the  Intestines. 

The  most  favorable  cases  of  intestinal  obstruction  for  laparotomy 
are  those  where  the  obstruction  is  due  to  constriction  from  a  narrow 
ligamentous  band.  The  history  of  such  cases  usually  points  to  an 
antecedent  attack  of  localized  peritonitis.  One  or  more  of  the 
adhesions  duringf  the  course  of  time  are  drawn  out  into  a  band  under 
which  the  intestine  is  caught,  and  strangulation  takes  place  in  the 
same  manner  as  in  strangulated  hernia.  These  are  the  cases  of 
intestinal  obstruction  which  if  left  alone  almost  without  exception 
result  in  death;  if  submitted  to  an  early  operation  they  are  cured  by 
one  stroke  of  the  scissors.  If  the  strangulated  loop  presents  no  evi- 
dence of  gangrene,  and  no  signs  of  decubitus  are  found  at  the  point 
of  compression  the  strangulation  is  relieved  by  cutting  the  band.  For 
the  purpose  of  preventing  a  recurrence  of  the  strangulation  from  the 
same  cause,  it  is  necessary  to  trace  the  band  to  its  points  of  fixation 
and  resect  it  between  two  ligatures.  A  diverticulum  of  the  small 
intestines,  remnants  of  the  vessels  of  the  vitelline  duct,  or  the 
appendix  vermiformis  have  often  been  found  as  causes  of  constric- 
tion when  the  free  extremity  of  these  structures  had  become  adhe- 
rent to  some  fixed  point.  It  is  always  necessary  to  make  a  close 
examination  of  a  constricting  band  before  resorting  to  cutting 
instruments,  as  a  mistake  in  recognizing  the  true  anatomical  charac- 
ter of  the  obstructing  cause  might  lead  to  serious  results.  A  narrow 
appendix  may  be  tied  and  resected  the  same  as  a  ligamentous  band, 
but  when  the  obstruction  is  caused  by  a  diverticulum,  greater  care 
must  be  exercised  in  removing  the  cause  of  obstruction.  Many  of 
the  diverticula  which  have  been  met  with  as  a  cause  of  obstruction 


58  INTESTINAL  SURGERY. 

were  nearly  as  large  at  their  base  as  the  intestine  with  which  they 
were  connected,  and  in  such  instances  it  would  be  unsafe  to  rely 
upon  a  ligature  at  the  resected  end  in  effecting  permanent  oblitera- 
tion, as  cutting  through  of  the  ligature  might  be  followed  by 
perforation,  and  death  from  septic  peritonitis  a  few  days  after  the 
apparent  recovery  of  the  patient.  The  proximal  end  of  such  a 
resected  diverticulum  must  be  closed  with  the  same  care  and  in  the 
same  manner  as  the  ends  of  the  intestine  after  permanent  interrup- 
tion of  its  continuity  by  resection,  and  its  function  by  anastomosis. 

If  the  obstruction  is  found  to  be  due  to  flexion,  the  mechanical 
difficulty  must  be  corrected  by  separating  the  adhesions,  as  the  apex 
of  the  flexion  is  generally  if  not  always  adherent  to  some  fixed  point; 
after  this  has  been  done  the  proper  shape  and  contour  of  the  bowel 
should  be  restored  and  its  permeability  tested  by  pushing  the 
contents  beyond  the  flexed  part,  and  if  this  can  be  done  without 
meeting  with  resistance,  and  the  condition  of  the  intestinal  walls  at 
the  site  of  flexion  presents  no  serious  textural  changes,  the  intestine 
is  returned  and  the  abdominal  incision  closed.  As  the  concavity  of 
the  flexion  is  usually  directed  towards  the  mesenteric  attachment  the 
vascular  disturbances  are  most  marked  on  the  convex  surface  of  the 
bowel,  and  if  gangrene  or  perforation  has  taken  place  it  is  found  at 
this  point.  In  either  of  these  events  it  would  become  necessary  to 
liberate  the  intestine  by  separating  the  adhesions  and  then  resort 
to  a  "V"  shaped  excision  on  the  convex  side  of  the  intestine.  The 
portion  to  be  excised  must  be  of  sufficient  size  to  include  the 
diseased  tissue  and  to  enable  the  surgeon  to  rectify  the  malposition 
after  suturing.  Immobilization  of  a  considerable  portion  of  the 
intestinal  canal  by  a  large  blood  clot  and  extensive  parietal  and 
visceral  adhesions  may  give  rise  to  symptoms  of  intestinal  obstruc- 
tion. When  intra-abdominal  haemorrhage  is  followed  by  a  complexus 
of  symptoms  indicative  of  the  presence  of  intestinal  obstruction, 
the  abdomen  should  be  opened  and  the  coagulated  blood  removed  by 
sponging  and  flushing  of  the  peritoneal  cavity  with  sterilized  water, 
and  the  recurrence  of  the  same  condition  prevented  by  arresting 
further  haemorrhage. 

A  form  of  visceral  adhesions  between  coils  of  intestines  massed 
into  a  bunch  has  already  been  described  as  a  cause  of  intestinal 
obstruction.  If  this  condition  has  lasted  for  several  days  and  the 
adhesions  have  become  firm,  it  is  absolutely  impossible  to  unravel 


DIRECT  TREATMENT  IN  STRANGULATION.  59 

the  gut  without  running  the  risk  of  inflicting  numberless  and  per- 
haps irreparable  injuries.  In  such  instances  excision  of  the  mass, 
followed  by  circular  enterorrhaphy,  or  anastomosis  between  the 
intestine  above  and  below  the  obstruction,  as  previously  described, 
present  themselves  as  the  most  appropriate  methods  of  treatment. 
Each  of  these  operations  is  applicable  to  special  cases  and  adapted 
to  meet  particular  indications.  Thus  if  any  of  the  embedded 
coils  should  present  indications  of  incipient  gangrene  resection 
must  be  done.  If  no  such  textural  changes  are  present  intestinal 
anastomosis  should  be  preferred,  as  by  it  the  obstruction  is  removed 
and  the  portion  temporarily  excluded,  after  subsidence  of  the  inflam- 
mation, and  absorption  of  the  adhesions,  may  again  become  perme- 
able and  resume  its  physiological  function.  Circumscribed  parietal 
adhesions,  as  a  cause  of  intestinal  obstruction,  are  most  frequently 
met  with  in  the  pelvis,  and  on  account  of  the  greater  frequency  of 
pelvic  inflammation  in  the  female  occur  more  frequently  in  women 
than  men.  Pelvic  intestinal  adhesions  produce  obstruction  in  two 
distinctly  difFerent  ways:  1.  An  adherent  intestine  becomes  flexed 
or  twisted  by  the  peristaltic  action  of  the  free  portions  and  obstruc- 
tion results  from  sudden  or  gradual  stenosis  of  the  lumen  of  the 
bowel.  2.  A  portion  of  intestine  becomes  fixed  at  either  end  by 
adhesions  and  a  loop  is  caught  under  it,  when  obstruction  is 
caused  in  the  same  manner  as  from  ligamentous  bands. 

The  only  case  of  intestinal  obstruction  after  ovariotomy  which 
occurred  in  my  practice  was  produced  in  this  manner.  The  pedicle 
was  tied  and  its  surface  cauterized.  No  untoward  symptoms  until 
the  end  of  the  third  week,  when  symptoms  of  intestinal  obstruction 
appeared  suddenly  and  increased  in  intensity  in  spite  of  irrigation  of 
the  stomach  and  high  rectal  injections.  She  died  two  weeks  later. 
The  post-mortem  showed  that  a  loop  of  the  lower  portion  of  the 
ileum  had  become  adherent  to  the  surface  of  the  pedicle,  and  that 
the  mesentery  constituted  the  second  fixed  point;  under  this  loop 
another  loop  four  inches  in  length  had  slipped  from  above  down- 
wards and  had  become  incarcerated  in  this  position.  The  intestine 
below  the  obstruction  was  perfectly  empty,  while  above  it  was  enor- 
mously dilated  and  exceedingly  vascular  as  far  as  the  duodenum. 

Quite  a  number  of  similar  cases  have  been  reported  by  different 
operators.  In  old  cases  of  pelvic  peritonitis  and  salpingitis  the 
cause  of  a  subsequent  attack  of  intestinal  obstruction  is  frequently 


60  INTESTINAL   SURGERY. 

traceable  to  intestinal  adhesions  and  the  formation  of  ligamentous 
bands.  In  the  separation  of  such  old  adhesions  the  greatest  care 
must  be  exercised  not  to  tear  the  bowel,  as  both  the  parietal  and 
visceral  peritoneum  may  have  been  transformed  into  a  cicatricial 
mass  which  it  is  not  safe  to  separate  by  tearing.  The  separation 
must  be  done  by  careful  dissection,  which  for  the  sake  of  safety  is 
done  rather  at  the  expense  of  the  parietal  than  the  visceral  tissues. 
Defects  of  the  peritoneum  thus  caused  or  made  during  other  abdom- 
inal operations,  should  be  covered  either  by  suturing,  by  laying  the 
omentum  over  it  or,  if  need  be,  by  omental  grafts  to  prevent  a 
recurrence  of  such  complication.  \  The  parietal  peritoneum  is  so 
loosely  attached  almost  everywhere  that  it  yields  sufficiently  to  cover 
a  defect  at  least  two  inches  in  width  by  suturing,  and  whenever  this 
can  be  done  it  should  not  be  neglected,  as  surfaces  denuded  of  peri- 
toneum are  liable  to  become  permanently  adherent  to  adjacent 
abdominal  viscera.*  \^When  the  omentum  is  within  reach  this  should 
be  utilized  in  covering  the  defects 

^  During  the  last  year  I  have  made  a  number  of  experiments  on 
animals,  which  demonstrate  that  when  a  piece  of  parietal  peritoneum 
three  to  four  inches  square  is  removed  and  not  restored  in  some  of 
the  above  ways,  permanent  adhesions  form  between  the  denuded 
place  and  the  organ  that  comes  in  contact  with  it.  Another  series 
of  experiments  which  it  would  be  too  tedious  to  describe  in  full, 
were  made  to  show  that  peritoneal  defects  which  cannot  be  restored 
by  suturing  or  covering  with  the  omentum  can  be  treated  success- 
fully by  transplantation  of  an  omental  or  peritoneal  graft.  In 
some  of  the  experiments  I  removed  from  each  side  of  the  abdominal 
wall  at  corresponding  points,  a  piece  of  peritoneum  four  inches 
square,  and  transplanted  the  pieces  to  opposite  points  and  sutured 
them  to  the  margins  of  the  wound  with  catgut.  All  of  these  ex- 
periments proved  successful.  Omental  grafts  answered  the  same 
purpose,  and  in  only  one  instance  did  the  graft  fail  to  unite 
thoroughly,  and  here  one  of  its  margins  projected  into  the  median 
abdominal  incision  which  did  not  unite  by  primary  union.  ;  Infection 
of  this  margin  led  to  gangrene  of  the  graft  and  septic  peritonitis. 

6.      Toilette  of  Peritoneal  Cavity. 

\    If   everything   that  has  come  in  contact  with  the  abdominal 
cavity   during   a   laparotomy    for   intestinal    obstruction,   has  been 


TOILETTE   OF  PERITONEAL   CAVITY.  61 

rendered  aseptic  by  the  most  scrupulous  antiseptic  precautions,  and 
the  local  conditions  found  have  caused  no  infection  and  no  soiling 
of  the  peritoneal  cavity  with  intestinal  contents  has  taken  place 
during  the  operation,  the  abdominal  cavity  is  aseptic  after  the 
operation  and  can  be  closed  after  the  removal  by  gentle  sponging,  of 
any  blood  that  may  have  collected.  Unnecessary  exposure  of  the 
intestines  should  always  be  most  carefully  guarded  against  by  com- 
presses around  the  incision  during  intra-abdominal  exploration,  and 
by  keeping  the  intestines  constantly  covered  by  warm  compresses  as 
long  as  they  are  outside  the  peritoneal  cavity,  for  the  pui-pose  of 
preventing  infection  by  floating  microbes  and  to  guard  against  loss 
of  heat  during  the  operation.  The  case  is,  however,  entirely 
diflPerent  when  the  parts  concerned  in  the  obstruction  have  caused 
intraperitoneal  sepsis  at  the  time  the  operation  is  undertaken,  or 
when,  during  its  performance,  in  spite  of  all  care  to  prevent  it,  the 
peritoneal  cavity  has  become  contaminated  by  faecal  extravasation. 
Under  these  circumstances  the  peritoneal  cavity  should  be  flushed 
with  gallons  of  sterilized  warm  water  in  which  one-tenth  per  cent,  of 
salicylic  acid  has  been  dissolved.  The  end  of  the  glass  tube  or 
rubber  tubing  of  the  fountain  syringe  should  be  held  in  different 
parts  of  the  abdominal  cavity,  especially  in  the  deepest  portion  of  the 
pelvis  and  the  lumbar  regions  so  as  to  direct  the  current  of  the  anti- 
septic solution  out  of  and  not  into  the  peritoneal  cavity.  After  the 
abdominal  cavity  has  been  cleansed  by  flushing,  it  is  dried  by 
sponges  wrung  out  of  a  1-5000  solution  of  sublimate.  '  In  such  cases 
drainage  should  never  be  omitted.  The  closure  of  the  external 
incision  when  intra-abdominal  pressure  is  excessive,  is  greatly  facili- 
tated by  covering  the  intestines  with  a  napkin  or  thin  compress  of 
gauze  which  is  tucked  underneath  the  margins  of  the  wound  all 
around.  The  sutures  should  be  all  introduced  before  any  of  them 
are  tied.  \  When  the  sutures  are  all  in  place  they  are  tied  from 
above  downwards.  If  tension  is  considerable  it  is  necessary  to 
add  two  or  more  button  sutures,  which  are  passed  down  only  to,  but 
not  through,  the  peritoneum,  and  are  removed  as  soon  as  the 
tympanites  disappears.  \ 

7.     Attek-Teeatment. 

*    Uniform  equable  support  of   the  abdomen  by  strapping  and 
bandages  over  the  antiseptic  absorbent  dressing  furnishes  efficient 


62  INTESTINAL  SURGERY. 

support  to  the  distended  abdominal  walls  and  the  paretic  intestines, 
and  is  not  only  grateful  to  the  patient  but  is  an  important  aid  in 
relieving  the  distress  due  to  distention  and  peristalsis.  I  have 
insisted  that  in  all  operations  for  intestinal  obstruction,  efforts  should 
be  made  to  empty  the  bowel  not  only  at  the  seat  of  obstruction, 
but  as  far  as  it  can  be  done,  as  such  immediate  evacuation  consti- 
tutes one  of  the  elements  of  success. 

J.  Greig  Smith  states  distinctly  that  VNo  case  of  operation  for 
intestinal  obstruction  is  properly  concluded  until  the  distended 
bowels  are  relieved  of  their  contents. '1  One  of  the  most  favorable 
symptoms  after  a  successful  operation  Tor  intestinal  obstruction  is  a 
spontaneous  action  of  the  bowels,  as  it  not  only  proves  the  permea- 
bility of  the  intestinal  canal,  but  is  also  an  evidence  that  peristaltic 
action  has  been  restored.  The  retention  of  fsecal  material  in  the 
distended  paretic  intestines  after  operation  for  intestinal  obstruction 
is  a  condition  which  not  only  retards  recovery,  but  is  in  itself  a 
grave  source  of  danger.  Through  the  sympathetic  nerves  the  dis- 
tended intestine  exerts  a  most  depressing  efPect  on  the  cerebro-spinal 
centers,  while  the  putrefactive  changes  which  are  constantly  going 
on  in  the  stagnant  intestinal  contents,  must  be  a  constant  source  of 
intoxication,  while  the  migration  of  septic  micro-organisms  through 
the  paretic  walls  threatens  life  from  septic  peritonitis. 

Mr.  Tait  has  taught  us  the  value  of  cathartics  in  the  prevention 
of  peritonitis  after  abdominal  operations.  Would  it  not  be  rational 
to  follow  his  example  in  the  after-treatment  of  operations  for  intes- 
tinal obstruction  ?  I  have  repeatedly  made  the  observation  that  the 
paretic  intestine  above  the  seat  of  obstruction  will  respond  slowly, 
but  surely,  to  mechanical  irritation,  and  it  is  only  logical  to  conclude 
that  the  same  efPect  would  be  produced  by  the  administration  of  a 
brisk  saline  cathartic.  Dangerous  as  the  use  of  cathartics  necessa- 
rily must  he  before  the  obstruction  is  removed,  so  beneficial  may  their 
judicious  employment  he  after  the  continuity  of  the  intestinal  canal 
has  been  restored  by  operative  treatment. 

'    IV.    Anatomico-Pathological  Forms  of  Obstruction. 

I.    Entero-lithiasis. 

a.    Biliary  calculi. 
The  term  intestinal  obstruction  in  the  strict  sense  of  the  word, 
is  applied  most  appropriately  to  that  form  of  obstruction  where  the 


ENTERO-LITHIASIS.— BILIARY   CALCULI.  63 

lumen  of  the  bowel  is  occupied  and  completely  closed  by  a  foreign 
body  or  an  enterolith.  A  foreign  body  introduced  into  a  healthy 
bowel,  even  if  it  completely  fills  its  lumen,  does  not  necessarily 
produce  intestinal  obstruction,  as  the  healthy  intestine  is  capable  of 
dilatation  to  a  sufficient  extent  to  furnish  an  outlet  to  fluid  intestinal 
contents  between  the  wall  of  the  bowel  and  the  foreign  body.  The 
following  experiments  were  made  for  the  purpose  of  studying  the 
effect  of  the  presence  of  a  foreign  body  of  sufficient  size  to  interfere 
with  the  passage  of  intestinal  contents,  and  also  with  a  view  of 
ascertaining  if  the  exclusion  of  peristaltic  action  of  a  certain  segment 
of  the  intestine  could  produce  intestinal  obstruction.  The  opera- 
tions were  performed  under  strict  antiseptic  precautions,  and  the 
abdominal  incision  was  always  made  through  the  linea  alba.  The 
animals  were  fed  on  the  coarsest  kind  of  food,  and  as  a  rule  their 
appetites  were  not  impaired  by  the  operation. 

Experiment  1.  Dog,  weight  thirty-four  pounds.  The  ileum  was  drawn 
forward  into  the  abdominal  wound,  and  an  incision  made  about  an  inch  in 
length,  on  the  convex  surface  about  twelve  inches  above  the  ileo-caecal  valve, 
and  through  this  opening  a  stiff  tube  four  inches  in  length,  and  three-quar- 
ters of  an  inch  in  diameter,  was  inserted  in  a  downward  direction.  The 
rubber  tube  distended  the  bowel  so  thoroughly  as  to  produce  a  limited  longi- 
tudinal rupture  of  the  peritoneal  coat.  This  tube  was  pushed  forward  as  far 
as  the  ileo-csecal  valve,  when  the  intestinal  wound  and  the  peritoneal  rent  were 
sutured.  The  visceral  wound  was  covered  with  an  omental  graft  which  was  of 
suflBcient  length  to  embrace  the  entire  circumference  of  the  intestine,  and  was 
fixed  in  its  place  by  two  catgut  sutures,  which  were  passed  through  the  mesen- 
tery and  both  ends  of  the  graft.  The  intestine  was  now  thoroughly  cleansed, 
dried,  and  returned,  and  the  abdominal  wound  closed.  The  tube  was  passed 
per  rectum  in  sixty  hours.  No  symptoms  of  obstruction  were  observed 
during  this  time,  and  the  animal  remained  in  perfect  health  until  killed  twenty 
days  after  the  operation.  The  intestinal  wound  was  recognizable  upon  the 
external  surface  of  the  bowel  by  a  ridge,  which  consisted  plainly  of  a  portion 
of  the  omental  flap;  the  remaining  portion  had  evidently  disappeared  by 
absorption,  at  least  it  had  become  invisible  to  the  naked  eye.  The  interior 
surface  of  the  bowel  along  which  the  rubber  tube  had  to  pass  on  its  way  out 
of  the  body  presented  nothing  abnormal. 

Experiment  2.  Dog,  weight  twenty-four  pounds.  In  this  instance  the 
incision  of  the  bowel  was  made  eighteen  inches  above  the  ileo-csecal  region, 
and  instead  of  a  rubber  tube  a  glass  tube  three  and  three-quarters  inches  in 
length,  and  half  an  inch  in  diameter,  was  introduced  and  pushed  along  the 
bowel  until  its  distal  end  was  within  six  inches  of  the  ileo-caecal  valve.  Omen- 
tal graft  over  the  visceral  wound.    No  symptoms.    Tube  passed  in  sixty-eight 


64  INTESTINAL   SURGERY. 

hours.     Dog  killed  fifty-seven  days  after  operation.    Intestinal  canal  through- 
out healthy.     Omental  graft  had  disappeared  completely. 

Experiment  3.  Dog,  weight  sixty-two  pounds.  Incision  of  bowel  twelve 
inches  above  ileo-csecal  region,  and  of  sufficient  size  to  permit  the  insertion 
of  a  glass  tube  five-eighths  of  an  inch  in  diameter,  and  six  inches  in  length, 
which  was  pushed  in  a  downward  direction  to  within  an  inch  of  the  ileo-csecal 
valve.  The  tube  filled  the  lumen  of  the  gut  completely,  but  produced  no 
tension  in  the  walls.  No  symptoms.  One  month  later  the  abdomen  was  again 
opened,  and  the  tube  was  found  in  the  descending  colon.  The  abdomen  was 
closed  and  the  tube  was  passed  per  rectum  four  days  later. 

In  these  experiments  hollow  tubes  were  used,  and  it  might  be 
claimed  that  intestinal  obstruction  was  not  produced  because  the 
fluid  intestinal  contents  could  pass  through  the  lumen  of  the  tube. 
The  effect  of  the  peristaltic  action  of  the  bowel  in  that  portion 
occupied  by  the  tube  was  certainly  eliminated  as  far  as  the  fsecal 
circulation  is  concerned,  and  yet  no  symptoms  of  obstruction  during 
life  were  observed,  and  the  post-mortem  appearances  indicated  that 
no  obstruction  had  existed  during  life.  It  is  certainly  surprising 
that  the  peristaltic  action  of  the  intestine  should  be  able  to  force  a 
rigid  tube  of  such  length  and  dimensions  as  were  used  in  the  last 
two  experiments  through  the  ileo-csecal  valve  into  the  colon. 

In  the  following  experiments  the  foreign  body  which  was  intro- 
duced was  of  such  a  structure  that  in  case  it  filled  the  entire  lumen 
of  the  bowel  it  would  of  necessity  produce  intestinal  obstruction, 
unless  a  space  for  the  passage  of  intestinal  contents  would  be  created 
between  the  foreign  body  and  the  intestinal  wall,  by  dilatation  of 
the  bowel. 

Experiment  4.  Dog,  weight  thirty-four  pounds.  Intestine  was  incised  at 
the  junction  of  the  ileum  with  the  jejunum  and  the  barrel  of  a  glass  female 
syringe  six  inches  in  length,  and  half  an  inch  in  diameter,  was  inserted  with 
the  closed  end  in  a  downward  direction.  The  animal  never  showed  any 
untoward  symptoms,  and  as  the  syringe  was  not  found  in  the  ftecal  discharges, 
the  animal  was  killed  six  weeks  later,  when  it  was  ascertained  that  it  must 
have  passed  at  some  previous  time  through  the  normal  outlet,  as  it  could  not 
be  found,  and  the  intestine  presented  throughout  a  normal  appearance. 

Experiment  5.  Dog,  weight  sixty  pounds.  In  this  experiment  the  incision 
in  the  bowel  was  made  thirty  inches  above  the  ileo-csecal  valve,  and  through 
it  was  inserted  with  considerable  force  a  glass  female  syringe  six  and  a  half 
inches  long  and  three-quarters  of  an  inch  in  diameter,  with  a  metal  cap  which 
considerably  increased  its  diameter  at  this  point.  The  piston  of  the  syringe 
projected  one  inch  and  a  half  from  the  cap.  The  perforated  end  of  the 
syringe  was  directed  downwards.  Visceral  wound  protected  by  a  circular 
omental  graft.     For  the  first  few  weeks  the  animal  appeared  to  be  in  good 


ENTERO-LITHIASIS.— BILIARY   CALCULI.  65 

condition,  and  the  faecal  discharges  were  normal.  Later  the  appetite  became 
impaired  and  the  last  few  days  obstinate  constipation  appeared.  The  dog 
was  killed  forty  days  after  the  insertion  of  the  foreign  body.  At  this  time  the 
syringe  could  be  plainly  felt  through  the  abdominal  wall.  The  syringe  was 
found  in  the  ascending  colon,  having  passed  through  the  ileo-ctecal  valve. 

The  ileo-csecal  region  was  distended  and  partially  obstructed  by  a  mass  of 
straw,  hair,  fragments  of  bone,  etc.,  for  a  distance  of  about  ten  inches. 
Above  this  point  the  bowel  was  considerably  dilated  and  contained  liquid 
faecal  matter.  Several  ulcerations  were  found  in  the  portion  of  ileum  traversed 
by  the  syringe.  The  lowest  ulcer  was  about  an  inch  and  a  half  in  length  and 
half  an  inch  wide,  reaching  as  far  as  the  ileo-csecal  valve,  and  apparently  of 
recent  date.  The  next  ulcer,  about  one  inch  longer,  but  of  the  same  width, 
was  found  six  inches  higher  up.  This  ulcer  presented  a  granulating  surface 
and  beginning  cicatrization.  The  third  point  of  ulceration  was  twelve  inches 
^bove  the  ileo-caecal  valve,  in  an  advanced  stage  of  cicatrization.  These  ulcers 
were  evidently  of  traumatic  origin  and  were  undoubtedly  caused  by  friction  of 
the  intestinal  wall  against^ the  projecting  point  of  the  piston,  in  the  attempts 
of  the  bowel  to  propel  the  foreign  body  by  increased  peristaltic  action.  In  this 
case  the  intestinal  obstruction  commenced  with  the  accumulation  of  solid 
material  on  the  proximal  side  of  the  syringe,  being  in  reality  not  caused  by 
the  foreign  body,  but  by  the  coprostasjs.  Had  this  latter  condition  not  devel- 
oped, the  foreign  body  would  undoubtedly  have  been  expelled  spontaneously, 
as  in  the  former  experiments. 

These  experiments  furnish  positive  proof  that  a  foreign  body  of 
sufficient  size  to  fill  the  entire  lumen  of  a  healthy  intestine  above 
the  ileo-csecal  valve  causes  no  obstruction,  and  that  when  obstruc- 
tion takes  place  in  such  instances,  it  is  caused  by  tissue  changes  in  the 
intestinal  wall  arising  from  prolonged  contact  with  the  foreign  body. 
In  reference  to  these  points  we  shall  consider  the  subject  of  entero- 
lithiasis  as  a  cause  of  intestinal  obstruction.  Entero-lithiasis  in 
man  is  due  in  the  great  majority  of  cases  to  the  impaction  of  a 
gall-stone  or  the  formation  of  an  enterolith  in  the  limien  of  the  bowel, 
the  nucleus  of  which  is  a  gall-stone.  It  has  been  a  disputed  ques- 
tion in  what  way  a  gall-stone  of  sufficient  size  to  give  rise  to  obstruc- 
tion could  enter  the  intestinal  canal.  Rokitansky  asserted  that  a 
calculus  the  size  of  a  hen's  Qgg  may  pass  through  the  bile-ducts. 
It  is  now  generally  believed  that,  as  a  rule,  at  least,  such  large  con- 
cretions can  only  escape  from  the  gall-bladder  by  ulceration  through 
its  walls,  or  that  a  gall-stone  of  smaller  size  after  it  has  passed 
through  the  bile-ducts,  subsequently  becomes  larger  by  the  forma- 
tion of  concentric  concretions  during  its  retention  in  the  intestinal 
canal.     In  reference  to  the  frequency  of  this  form  of  obstruction 


66  INTESTINAL  SURGERY. 

Leichtenstern  has  found  that  out  of  fifteen  hundred  and  fortj-one 
cases  of  intestinal  obstruction  with  different  causes,  tabulated  by 
himself,  forty-one  were  produced  by  gall-stones. 

-  Wising'  collected  fifty-one  cases  of  intestinal  obstruction  caused 
by  the  presence  of  biliary  calculi,  with  the  result  that  in  only 
twenty-four  of  them  could  the  anatomical  condition  of  the  gall- 
bladder be  ascertained.  In  eighteen  of  these  the  post-mortem 
appearances  showed  that  the  calculus  had  entered  the  intestine  from 
the  gall-bladder  by  a  process  of  ulceration,  and  only  in  three  cases 
it  appeared  as  though  the  calculus  had  passed  througn  the  common 
bile-duct.  In  thirty -three  cases  the  place  of  obstruction  was  twelve 
times  the  jejumun,  and  twenty-one  times  the  ileum.  In  the  twenty- 
one  cases  where  the  calculus  was  impacted  in  the  ileum,  the  seat  of 
obstruction  in  two  was  in  the  middle,  in  six  in  the  upper  half,  and  in 
twelve  in  the  lower  half  of  this  portion  of  "intestine.  Icterus  was 
observed  only  in  eight  of  the  fifty  one  cases.  The  prognosis  is 
always  very  grave,  as  of  the  fifty-one  cases  thirty-eight  died.  In 
twenty-five  fatal  cases,  death  occurred  fourteen  times  between  the 
sixth  and  tbe  eighth  day,  while  in  isolated  cases  it  did  not  occur 
until  from  the  ninth  to  the  twenty  eighth  day,  and  one  patient  died 
after  two  months  from  perforative  peritonitis.  Taking  all  cases  of 
obstructions  from  gall-stones  together,  we  can  say  that  the  seat 
of  obstructions  is  located  in  the  lower  portion  of  the  ileum  in  fifty 
per  cent,  of  the  cases.  The  upper  part  of  the  jejunum  is  the  next 
most  frequent  site  of  obstruction,  and  in  a  few  cases  the  gall-stone 
becomes  impacted  in  the  duodenum  at  the  site  where  it  has  ulcerated 
through  the  walls  of  the  gall-bladder  and  intestine.  In  thirty-two 
cases  collected  by  Leichtenstern,  the  gall-stone  occupied  the  duode- 
num and  jejunum  in  ten  cases,  middle  of  ileum  in  five  cases,  lower 
part  of  ileum  in  seventeen  cases. 

Treves  is  of  the  opinion  that  gall-stones  causing  intestinal 
obstruction  ulcerate  directly  into  the  intestine.  He  had  collected 
forty- eight  cases  of  obstruction  due  to  gall-stones.  In  the  majority 
of  cases  direct  evidence  of  ulceration  between  the  gall-bladder 
and  duodenum  was  to  be  obtained.  The  gall-bladder  was  entirely 
disorganized  in  a  case  in  which  the  gall-stone  was  supposed  to 
have  traversed  the  biliary  ducts.     When  impaction  takes  place  high 

1  Ueber  Gallenstein  ileus.     Nord  Med.  Archiv.,  B.  XVII,  No.  18. 


ENTERO-LITHIASIS— BILIARY   CALCULI.  67 

up  in  the  intestinal  tube,  tympanites  may  be  entirely  wanting  and 
the  symptoms  point  rather  to  the  existence  of  pyloric  stenosis  than 
intestinal  obstruction.  The  higher  the  location  of  the  impaction 
the  greater  the  probability  that  the  calculus  attained  its  size 
within  the  biliary  passages,  and  that  it  entered  the  intestine  by  a 
process  of  ulceration.  In  some  cases  the  communication  between 
the  gall  bladder  and  the  duodenum  remained  at  the  time  of  death, 
showing  that  perforation  had  only  recently  taken  place.  Wising 
has  reported  such  a  case.  The  patient  was  a  woman,  seventy  years 
of  age,  who  had  never  suffered  from  biliary  colic  or  jaundice.  The 
attack  of  intestinal  obstruction  was  acute,  faecal  vomiting  being 
an  early  symptom,  slight  icterus  and  little  tympanites,  death  on 
the  fifth  day.  At  the  necropsy  a  biliary  calculus  7  cm.  in  length 
and  10  cm.  in  circumference  was  found  firmly  impacted  in  the 
ileum.  The  intestine  on  the  proximal  side  was  found  greatly 
distended  and  of  a  color  suggesting  incipient  gangrene,  while  the 
bowel  below  the  obstruction  was  pale  and  contracted.  Gall-bladder 
ulcerated  and  contracted  by  cicatricial  tissue  coilimunicating  with 
the  duodenum  by  a  perforation  above  the  common  bile-duct.  A 
smaller  communication  was  also  found  between  the  gall-bladder 
and  the  transverse  colon.  Shattock'  mentions  a  case  under  the 
care  of  Dr.  Bristowe,  in  which  the  remains  of  the  gall-bladder, 
which  was  very  small,  communicated  directly  with  the  intestine. 

In  some  cases  the  pathological  conditions  within  and  around  the 
gall-bladder  show  evidences  which  go  to  prove  that  perforation  had 
taken  place  long  before  the  development  of  the  intestinal  obstruc- 
tion. In  such  cases  the  gall-stone  must  have  occupied  the  intestinal 
canal  for  a  variable  period  of  time  without  having  given  rise  to 
obstruction,  the  intestinal  contents  passing  between  it  and  the  intes- 
tinal wall  in  the  same  manner  as  in  the  experiments  detailed  above. 
In  some  cases  the  gall-stone  becomes  encysted  and  symptoms  of 
obstruction  are  not  produced  until  the  size  of  the  stone  has  increased 
by  the  addition  of  concentric  layers  of  concretion.  Harley "  reported 
a  case  where  a  gall-stone  became  encysted  in  the  duodenum. 
Woodbury^  reports  a  case  that  came  under  the  observation  of  Dr. 
T.  H.  Andrews,  of  a  woman  sixty  years  of  age,  who  was  suddenly 

1  British  Medical  Journal,  March  19,  1887. 

2  Path.  Soc.  Transactions,  London,  vol.  VIII. 
^  Amer.  Jour.  Med.  Sciences,  January,  1880. 


68  INTESTINAL   SURGERY. 

attacked  with  symptoms  of  acute  intestinal  obstruction  without 
having  previously  suffered  from  any  disorder  of  the  biliary  passages. 
She  died  on  the  seventh  day.  A  concretion  the  size  of  an  English 
walnut  was  found  firmly  impacted,  in  the  upper  portion  of  the 
jejunum.  Upon  section  the  concretion  was  seen  to  consist  of  a 
brown,  friable,  cortical  substance,  enveloping  a  dense,  white  crystal- 
line body  as  large  as  a  cherry,  which  was  evidently  cholesterine.  It 
appears  that  in  this  case  a  small  gall-stone  which  had  passed 
through  the  bile-ducts  without  producing  symptoms,  was  in  some 
way  retained  high  up  in  the  intestine,  and  served  as  a  nucleus  for 
the  formation  of  an  enterolith  of  sufficient  size  to  give  rise  to  intes- 
tinal obstruction. 

Barlow'  reports  the  case  of  a  woman  fifty-seven  years  of  age 
who  had  symptoms  of  gall-stones  for  a  year.  She  suddenly  devel- 
oped an  acute  intestinal  obstruction  from  which  she  died.  About 
the  center  of  the  ileum  there  was  found  a  biliary  calculus  of  the  size 
of  a  walnut,  partially  sacculated.  In  some  rare  cases  the  obstruction 
is  caused  by  the*  retention  of  numerous  calculi  in  a  circumscribed 
portion  of  the  bowel.  Metcalfe  ^  presented  to  the  New  York  Patho- 
logical Society  a  specimen  taken  from  a  man  fifty -four  years  of  age, 
where  the  duodenum  was  occupied  by  numerous  gall-stones  in  such  a 
way  as  to  give  rise  to  complete  obstruction. 

A  calculus  may  attain  great  size  before  it  becomes  impacted. 
Smith  ^  observed  a  case  of  acute  intestinal  obstruction  which  proved 
fatal  on  the  fifth  day,  where  the  post-mortem  revealed  the  cause 
to  be  a  biliary  calculus  measuring  four  and  a  half  by  two  and  a  half 
inches  in  circumference,  which  was  found  impacted  in  the  jejunum 
thirty  inches  below  the  pyloric  orifice  of  the  stomach. 

Clark*  relates  the  case  of  a  woman  fifty-eight  years  of  age  who 
died  of  acute  intestinal  obstruction,  where  two  large  gall-stones  were 
found  impacted  immediately  above  the  ileo-caecal  valve,  each  of 
which  was  one  inch  in  length  and  four  inches  in  circumference, 
and  together  weighed  one  and  one-fourth  ounces.  The  stones 
were  composed  of  cholesterine  and  coloring  material  of  bile.     The 

1  Guy's  Hospital  Reports,  1884. 

2  Transactions  New  York  Pathological  Society,  vol.  II,  pp.  2,  3. 
^  Pathological  Society's  Transactions,  London,  1854. 

*  A  Case  of  Large  Biliary  Concretion  in  the  Ileum.  Medico-Chirurg.  Trans., 
vol.  55,  p.  1. 


ENTERO-LITHIASIS.— BILIARY   CALCULI.  69 

intestine  was  perforated  at  the  seat  of  impaction  and  a  number  of 
small  gall-stones  was  found  in  the  peritoneal  cavity.  The  biliary 
passages  were  dilated  and  thickened,  but  the  gall-bladder  appeared 
to  be  normal  in  size  and  structure  and  not  adherent  to  the  duodenum ; 
jaundice  had  never  existed.  Eight  months  previous  to  the  last  ill- 
ness she  had  a  similar  attack  of  obstruction  and  at  that  time  a  firm 
tumor  could  be  felt  in  the  right  hypochondriac  region.  This  and 
the  next  case  illustrate  that  the  great  danger  of  impaction  of  a  gall- 
stone consists  of  textural  changes  of  the  intestine  at  the  site  of 
impaction.  Meymott's'  patient  was  a  woman  forty-seven  years  old, 
who  died  after  a  short  illness  during  which  symptoms  of  intestinal 
obstruction  were  well  marked.  At  the  necropsy  a  gall-stone  com- 
posed of  cholesterine,  and  weighing  four  hundred  grains  was  found 
impacted  in  the  ileum  four  inches  above  the  ileo-csecal  valve.  At 
the  seat  of  impaction  circumscribed  gangrene  and  perforation  had 
taken  place. 

'  Fagge, '•*  in  his  excellent  paper  "On  Intestinal  Obstruction", 
gives  an  account  of  a  case  which  he  examined  where,  in  a  woman 
sixty-nine  years  of  age,  who  had  died  with  symptoms  of  intestinal 
obstruction,  a  gall-stone  measuring  four  and  a  half  inches  in  its 
largest  circumference  and  two  and  a  half  inches  in  its  smallest,  was 
found  impacted  in  the  jejunum  thirty  inches  below  the  pyloric  orifice 
of  the  stomach.  The  stone  had  passed  from  the  gall-bladder  into 
the  duodenum  through  a  perforation,  firm  adhesions  having  pre- 
vented its  escape  into  the  peritoneal  cavity.  In  two  other  cases  to 
which  the  same  author  refers,  the  patients  suffered  from  intestinal 
obstruction,  and  recovery  followed  after  the  evacuation  of  gall-stones 
of  immense  size.  In  cases  terminating  by  spontaneous  recovery  he 
believes  that  perforation  takes  place  into  the  colon.  That  the  danger 
is  not  always  passed  when  a  large  biliary  calculus  enters  the  colon 
directly  through  a  perforation  of  the  gall-bladder  is  well  illustrated 
by  a  case  reported  by  Bourdon,^  where  the  calculus  became  lodged 
in  the  sigmoid  flexure,  where  it  produced  an  inflammation  which 

*  Impaction  of  a  Large  Gall-stone  in  the  Ileum.  The  Lancet,  April 
27,  1872. 

^  On  Intestinal  Obstruction.     Guy's  Hospital  Reports,  vol.  XIV. 

•''  Calcul  biliare  d'un  volume  considerable,  tombe  dans  le  tube  digestif  h. 
travers  les  parois  perforees  de  la  vesicule  et  du  colon  transverse.  Gaz.  des 
HSpitaux,  No.  72,  1859. 


70  INTESTINAL  SURGERY. 

proved  fatal.  In  a  number  of  cases  recovery  took  place  by  discharge 
of  the  calculus  per  viam  naturalis  even  after  the  symptoms  had 
pointed  to  complete  obstruction.  The  largest  stone  which  has  been 
successfully  passed  was  three  and  a  half  inches  in  circumference. 
Pye-Smith^  narrates  a  case  which  tends  to  show  that  in  cases 
of  intestinal  obstruction  due  to  the  presence  of  a  biliary  calculus,  a 
spontaneous  cure  is  possible  even  after  the  symptoms  have  continued 
for  a  number  of  days.  The  patient  was  a  female  seventy-eight  years 
of  age  who  had  never  suffered  from  jaundice,  and  gave  no  history  of 
biliary  colic.  She  had  always  been  very  constipated;  obstruction 
finally  ensued;  and  after  some  temporary  relief  became  complete. 
By  external  palpation  no  tumor  could  be  felt.  On  rectal  examina- 
tion, however,  the  finger  could  just  reach  a  smooth,  hard,  movable 
tumor,  and  it  seemed  probable  that  there  was  malignant  disease  of 
the  colon.  After  thirteen  days  of  complete  obstruction,  however,  a 
large  gall-stone  was  passed,  and  the  patient  recovered  quickly,  and 
subsequently  remained  free  from  the  trouble. 

Treatment. 

Foreign  bodies  when  impacted  in  the  intestine  set  up  inflam- 
mation, and  this  may  go  on  to  gangrene  and  perforation,  and  so  it 
can  be  explained  how  cathartics  under  such  circumstances  are  more 
likely  to  do  harm  than  good.  If  impaction  has  taken  place  near 
the  ileo-csecal  valve  or  in  the  colon,  large  injections  and  massage 
may  be  tried,  provided  symptoms  of  severe  inflammation  or  gangrene 
at  the  site  of  impaction  are  absent.  In  the  great  majority  of  cases, 
however,  the  local  lesions  at  the  site  of  impaction  are  of  such  a 
nature  at  the  time  surgical  aid  is  summoned,  that  nothing  short  of  a 
laparotomy  will  promise  any  hope  of  success.  It  will  be  well  for 
the  surgeon  not  to  place  too  much  importance  upon  the  presence  of 
tympanitic  distention  of  the  abdomen  in  these  cases  as  an  indication 
for  the  necessity  of  an  abdominal  section,  as  this  sign  may  bo 
entirely  absent  if  the  impaction  is  located  high  up  in  the  intestinal 
tract,  and  if  the  impaction  is  in  the  lower  part  of  the  ileum  or  colon 
an  operation  should  not  be  postponed  until  such  distention  has  taken 
place.  After  the  abdomen  has  been  opened  in  the  median  line,  and 
the  seat  of  obstruction  determined,  the  course  to  be  pursued  will 
depend  upon  the  pathological  conditions  at  the  seat  of  impaction. 

^  British  Medical  Journal,  March  }9,  1887. 


BILIARY   CALCULL—TREATMENT.  71 

As  the  mucous  membrane  in  contact  witli  the  f oregn  body  is  always 
*first  to  suflPer  in  consequence  of  the  impaction,  puncture  and  incision 
should  be  avoided  at  this  point. 

As  the  cases  must  be  few  where  such  a  stone,  even  soon  after 
impaction  has  taken  place,  can  be  pushed  along  the  intestinal  canal 
and  through  the  ileo-csecal  valve  into  the  colon,  submural  crushing 
of  the  stone  should  be  practiced  where  attempts  at  distant  displace- 
ment have  failed,  and  where  the  condition  of  the  intestinal  wall 
is  such  that  no  fear  need  be  entertained  that  gangrene  or  perfora- 
tion will  take  place.  The  stone  should  never  be  attacked  at  the  seat 
of  impaction,  but  should  be  pushed  in  an  upward  or  downward 
direction,  and  then  removed  if  possible  by  breaking  it  up  by  manual 
pressure,  or,  if  this  fail,  the  method  suggested  by  Tait^  of  passing 
in  a  needle  obliquely  through  the  intestinal  wall  and  attacking  the 
calculus  in  this  manner  may  be  tried.  A  stout  steel  needle,  such  as 
is  used  for  electrolysis,  is  best  adapted  for  this  purpose.  The  needle 
should  always  be  introduced  obliquely  through  the  intestinal  wall  an 
inch  or  two  below  the  impaction  in  order  to  secure  healthy  tissue  for 
the  seat  of  puncture.  After  the  stone  has  been  crushed  and  the 
debris  within  the  gut  has  been  pushed  into  a  healthy  segment  of 
bowel  below,  the  puncture  in  the  serous  coat  should  be  closed  by 
drawing  the  peritoneum  over  it  with  a  fine  superficial  suture  for  the 
purpose  of  guarding  against  leakage. 

When  efforts  at  submural  crushing  or  fracturing  of  the  entero- 
lith have  failed  and  it  is  deemed  necessary  to  excise  it,  it  is  also 
advisable  to  push  the  foreign  body  within  the  gut  in  an  upward  or 
downward  direction  sufficiently  far  to  bring  it  to  a  perfectly  healthy 
portion  of  the  intestine,  as  the  healing  process  of  the  visceral  wound 
made  for  its  extraction  would  proceed  more  satisfactorily  here  than 
where  the  tunics  of  the  intestine  had  undergone  pathological 
changes  in  consequence  of  the  impaction.  If  the  stone  cannot  be 
displaced  and  the  incision  must  •  be  made  through  an  inflamed 
intestinal  wall  a  graft  of  omentum  should  be  placed  around  the 
intestine,  after  suturing  the  visceral  wound  so  as  to  cover  the 
wound,  and  its  ends  fastened  together  by  two  sutures  passed  through 
the  mesenteric  attachment.  Such  a  procedure  will  place  the  visceral 
wound  in  the  very  best  condition  for  healing  and  will  furnish  an 


^  The  Lancet,  December  10,  1887. 


72  INTESTINAL  SURGERY. 

additional  safeguard  against  subsequent  perforation.  If  the  intes- 
tine at  the  site  of  impaction  shows  evidences  of  gangrene  or  if 
perforation  has  already  taken  place  no  efforts  should  be  made  to 
extract  the  stone,  as  under  such  circumstances  the  surgeon  is 
compelled  to  resect  that  portion  of  intestine  in  which  the  stone  is 
imprisoned.  As  patients  presenting  such  conditions  are  always 
more  or  less  collapsed  it  becomes  of  the  greatest  importance  to  finish 
the  operation  as  rapidly  as  possible ;  consequently  after  the  resection 
has  been  made  in  the  usual  manner,  the  continuity  of  the  intestinal 
canal  should  be  restored  by  an  operative  procedure  which  can  be 
executed  without  unnecessary  loss  of  time. 

As  the  bowel  above  the  seat  of  obstruction  is  always  found 
greatly  dilated,  circular  enterorrhaphy  for  this  reason  alone  would 
be  a  difficult  if  not  impracticable  task ;  hence  both  ends  of  the  intes- 
tine should  be  invaginated  to  the  extent  of  an  inch  and  the  invagi- 
nation maintained  by  three  or  four  superficial  stitches  of  the  con- 
tinued suture,  and  the  continuity  of  the  intestinal  canal  restored  by 
making  an  incision  an  inch  in  length  in  each  closed  end  of  the  bowel, 
on  the  convex  surface  about  two  inches  from  the  sutured  extremity, 
and  lateral  apposition  of  the  wounds  secured  by  decalcified  perfo- 
rated bone  plates.  This  method  should  always  be  preferred  to  circu- 
lar enterorrhaphy  in  uniting  the  bowel  after  resection  under  such 
circumstances,  as  the  extensive  and  secure  coaptation  of  serous  sur- 
faces greatly  enhances  the  chances  of  early  imion  between  the  coap- 
tated  bowels,  and  at  the  same  time  establishes  a  communicating 
opening  equally  serviceable  as  that  after  circular  suturing. 

b.    Intestinal  Concretions. 

We  have  already  seen  that  a  small  gall-stone  when  retained  for 
a  sufficient  length  of  time  in  the  intestinal  canal  may  become  the 
nucleus  for  an  intestinal  concretion,  which  by  the  addition  of 
concentric  layers  gradually  increases  in  size  until  it  fills  the  lumen 
of  the  bowel,  and  after  its  impaction  gives  rise  to  intestinal  obstruc- 
tion. Enteroliths  causing  obstruction  have  been  found  in  which  a 
variety  of  foreign  bodies  have  been  found  as  nuclei. 

Cloquet^  divides  the  concretions  found  in  the  alimentary  canal 
into  two  classes.  The  first  includes  enteroliths  in  man,  and  bezoars 
in  animals,  both  being  the  result  of  calcareous  deposits  secreted  by 

^  Amer.  Jour.  Med.  Sciences,  January,  1856,  p.  216. 


ENTERO-LITHIASIS.— INTESTINAL   CONCRETIONS.  73 

the  parieties  of  the  intestines.  The  second  class  comprises  abnormal 
masses,  such  as  solids,  (animal  or  vegetable  hairs  which  have  escaped 
the  process  of  digestion,  and  agglomerate  to  form  segagropili), 
pulverulent  substances,  and  foreign  bodies,  such  as  kernels  of  fruit, 
biliary  calculi,  and  hardened  faeces.  He  described  an  enterolith 
which  formed  around  a  pin  as  a  nucleus,  by  deposits  of  phosphate  of 
lime  and  which  had  become  arrested  in  the  csecum,  where  it  caused 
the  death  of  the  patient.  In  another  case  he  found  that  the  nucleus 
was  composed  of  an  ivory  pessary  which  had  perforated  the  bowel  on 
one  side  and  the  bladder  on  the  other.  The  perforation  of  the  bowel 
was  covered  by  a  concretion  of  phosphate  of  lime,  while  the  part  in 
the  bladder  was  encrusted  with  uric  acid. 

Aberle  ^  reported  a  case  where  chronic  intestinal  obstruction  was 
caused  by  the  presence  of  thirty-two  enteroliths,  each  of  which  was 
composed  of  a  concretion  in  concentric  layers  around  a  cherry  stone 
as  a  nucleus.  '  The  concretions  had  collected  in  the  colon  and  were 
successfully  removed  by  rectal  injections  and  cathartics.  A  chemical 
examination  of  the  concretion  showed  that  it  was  composed  of 
phosphate  of  lime  and  a  considerable  quantity  of  fat,  animal  glue, 
and  traces  of  cholesterine. 

^  Schoor'^  described  an  enterolith  which  for  five  years  had  given 
rise  to  pain,  first  in  the  ileo-csecal  region  and  later  in  the  left  inguinal 
region,  and  was  finally  discharged  spontaneously.  It  measured 
four  and  one-half  inches  in  length  and  2.9  inches  in  width  and 
weighed  44.9  grammes.  On  making  a  section  of  it,  it  was  found 
that  the  central  portion  or  nucleus  was  composed  of  a  triangular 
piece  of  bone  around  which  in  concentric  layers  the  concretion  was 
arranged.  A  chemical  examination  of  the  concretion  showed  that 
it  was  largely  composed  of  phosphate  of  ammonia  and  magnesia, 
the  remaining  part  of  it  consisting  of  vegetable  fibres,  coloring 
material  of  bile,  cholesterine,  and  chloride  of  sodium. 

Virchow'^  made  a  careful  chemical  and  microscopical  examination 
of  an  enterolith  which  had  caused  symptoms  of  obstruction  in  a 
woman,  but  was  finally  expelled  after  a  severe  attack  of  colica  ster- 
coralis.     The  stone  measured  5  cm.  in  length  and  8.5  cm.  in  its 

'  Ein  Fall  von  Steinbildung  in  Darmkanale.     Wurt.  Med.  Corresp.  blatt, 
No.  23,  1868. 

^Canstatt's  Jahresbericht,  B.  2,  1853,  p.  64. 
3  Virchow's  Archiv.  B.  XX,  Heft  3  u.  4, 


74  INTESTINAL  SURGERY. 

greatest  circumference.  On  making  a  section  through  the  center 
it  was  seen  to  be  composed  of  a  plum-stone  surrounded  by  a  shell 
2  cm.  in  thickness,  made  up  of  concentric  layers  of  crystalline  bodies 
held  together  by  a  brownish  mass.  Chemical  analysis  showed  that 
the  shell  was  composed  largely  of  phosphate  of  ammonia  and 
magnesia. 

In  Friedlander's^  case  the  obstruction  was  due  to  the  impaction 
of  an  enterolith  in  the  ileum  30  cm.  above  the  ileo-csecal  valve, 
which  was  composed  of  shellac.  The  patient  was  a  cabinet-maker, 
and  it  is  said  that  the  apprentices  of  this  trade  not  infrequently 
consume  the  alcoholic  solution  of  shellac  used  for  varnishing;  in  the 
stomach  the  alcohol  is  absorbed,  and  the  shellac  is  deposited.  In 
this  case  the  stomach  contained  a  large  number  of  the  same  kind  of 
concretions. 

^  At  the  meeting  of  the  Congress  of  German  Surgeons  in  Berlin, 
in  April,  1880,  Langenbuch^  showed  some  large  concretions,  some 
of  which  he  had  removed  by  enterotomy  in  a  patient  who  had  suffered 
from  repeated  attacks  of  intestinal  obstruction.  As  the  symptoms 
tecame  more  urgent  and  failed  to  yield  to  simpler  measures,  abdom- 
inal section  was  performed  in  the  median  line,  and  the  operator 
without  much  difficulty  found  a  swelling  in  the  jejunum,  laid  open 
the  intestine,  and  removed  the  mass  of  concretions  which  completely 
tilled  the  lumen  of  the  bowel.  Vomiting  continued  and  the  patient 
died  a  few  hours  after  the  operation.  The  necropsy  revealed  a 
second  mass  still  larger,  in  the  pyloric  region  of  the  stomach.  Virchow 
examined  the  concretions  and  found  that  they  consisted  almost  exclu- 
sively of  organic  substance,  and  especially  of  the  derivative  of  the 
biliary  acids  known  as  dyslysin. 

The  surgical  treatment  of  intestinal  concretions  is  the  same  as 
in  cases  of  impacted  gall-stones. 

c.    Parasites  as  a  Cause  of  Intestinal  Obstruction. 

A  few  cases  of  intestinal  obstruction  have  been  recorded  where 

•the  obstruction  was  caused  by  a  mass  of  ascarides  which  interfered 

with  the  passage  of  intestinal  contents  in  the  same  manner  as  an 

'  Schellack-steine  als  TJrsache  von  Ileus.     Berl.     Klin.  Wochenschrift,  No. 
1,  1882. 

2  Verh.  der  deutschen  Gesellschaft  f .  Chirurgie,  1880. 


ENTERO-LITHIASIS.— PARASITES  AS  A    CAUSE.  75 

enterolith.  Halma-Grtmd'  refers  to  a  patient  ten  years  of  age  that 
came  under  his  care  suffering  with  the  characteristic  symptoms  of 
acute  intestinal  obstruction,  followed  by  haemorrhage  from  the 
bowels,  collapse  and  death.  The  necropsy  revealed  as  the  cause  of 
obstruction  a  mass  of  ascarides  eighteen  in  number  which  completely 
filled  the  lumen  of  the  ileum.  At  the  site  of  impaction  an  ulcer  was 
found  showing  an  eroded  vessel  which  had  been  the  source  of 
haemorrhage. 

Saurel's^  patient  was  twenty-three  years  of  age,  who  suffered 
from  symptoms  which  resembled  closely  an  attack  of  intestinal 
obstruction.  A  swelling  could  be  felt  to  the  left  of  the  umbilicus. 
Two  ascarides  were  thrown  up  during  a  severe  attack  of  vomiting. 
Anthelmintics  were  administered  and  injections  given  without  any 
effect,  and  the  patient  died  in  collapse.  The  necropsy  revealed  the 
cause  of  obstruction  to  have  been  a  mass  of  ascarides  which  were 
firmly  impacted  in  the  lower  part  of  the  ileum. 

Pockels^  was  called  to  attend  a  patient  who  had  suffered  for 
some  time  from  an  intra-abdominal  swelling  the  size  of  a  hen's  egg 
which  could  be  distinctly  felt  below  and  to  the  left  of  the  umbilicus. 
A  ptirge  of  male  fern  and  jalap  expelled  one  hundred  and  three 
ascarides,  after  which  the  tumor  disappeared  and  the  patient's  health 
was  completely  restored. 

Stepp*  has  recently  recorded  an  instance  in  a  boy,  aged  four, 
who  died  with  symptoms  of  acute  intestinal  obstruction  an  hour  and 
a  half  after  medical  aid  was  summoned.  The  post-mortem  showed 
that  the  intestine  was  completely  obstructed  by  a  twisted  mass  of 
some  forty  or  fifty  round  worms,  lodged  just  above  the  ileo-csecal 
valve.  The  ileum  contained  about  thirty-five  more,  higher  up,  and 
there  were  a  few  in  the  stomach  and  oesophagus.  The  mother  of 
the  child  had  given  the  patient  some  worm  medicine  a  few  days 
before  the  acute  attack,  and  Stepp  thinks  that  the  worms,  weakened 
by  the  medicine,  were  dislodged  in  numbers  by  the  violent  peristalsis 


1  Enteritis    Verminosa.      Mit    Darmblutung    u.    Einklemmungserschein- 
ungen.    Schmidt's  Jahrbiicher,  B.  99,  p.  92. 

2  Darmverstopfung  durch  Wtirmer.     Schmidt's  Jahrbiicher,  B.  99,  p.  92. 
^Briefliche  Nachrichten  iiber    Rundwtirmer.       Schmidt's  Jahrbiicher,  B. 

99,  p.  92. 

*  Centralblatt  f .  die  med.  Wissensch,  No.  27,  1888. 


76  INTESTINAL  SURGERY. 

set  tip  by  an  injudicious  diet  afterwards,   and  so  rolled   down  in 
a  tangled  mass  too  large  to  pass  the  ileo-csecal  valve. 

When  the  surgeon  is  called  upon  to  treat  a  case  of  intestinal 
obstruction  in  a  child,  such  a  cause  should  be  borne  in  mind,  as  in  a 
case  of  this  kind,  a  timely  anthelmintic  remedy  followed  by  a  brisk 
cathartic  may  prove  efficient  in  removing  the  cause  of  obstruction. 
If  such  treatment  should  prove  unavailing,  no  time  should  be  lost  in 
resorting  to  operative  treatment  by  abdominal  section,  which  is  to  be 
conducted  in  the  same  manner  as  in  operations  for  intestinal  con- 
cretions, 

d.    Fsecal  Obstruction. 

Fsecal  obstruction  is  almost  without  exception  met  with  only  in 
the  large  intestine,  and  here  in  preference,  in  the  csecal  region  or  in 
the  sigmoid  flexure.  Cases  have  been  reported  where  a  congenital 
abnormal  dilatation  of  some  part  of  the  colon  predisposed  to  this 
afPection.  The  acquired  form  of  dilatation  which  attends  all  cases  is 
the  result  of  prolonged  overdisteution  resulting  in  paresis  of  the 
distended  segment  of  the  bowel. 

Boys  de  Loury '  has  collected  a  number  of  cases  of  retention  of 
f  seces  in  the  crecum  and  colon  which  finally  gave  rise  to  inflammation 
at  the  seat  of  impaction,  and  intestinal  obstruction.  Among  them 
was  one  observed  by  N6laton,  where  the  fsecal  tumor,  occupying  the 
caecum  and  ascending  colon,  by  pressure  against  the  under  surface  of 
the  liver  and  gall-bladder,  caused  icterus.  The  icterus  and  symptoms 
of  obstruction  disappeared  promptly  after  the  removal  of  the  faecal 
accumulation  by  cathartics.  Retention  of  faeces  after  a  time  pro- 
duces more  or  less  acute  enteritis,  attended  by  tympanites,  pain,  and 
dyspnoea.  The  patients  usually  have  been  constipated  for  a  long  time, 
sometimes  alternating  with  diarrhoea.  The  retained  faeces  become 
inspissated  and  hard  and  form  mural  concretions,  the  middle  often 
remaining  tunneled  for  the  passage  of  fluid  faeces.  The  masses  are 
modelled  and  when  thrown  off  often  describe  in  accurate  outline  the 
contour  of  the  bowel.  Distention  of  the  bowel  often  takes  place  to 
an  enormous  extent.  Cruveilhier  found  on  making  a  necropsy  on  an 
old  man,  the  transverse  colon  so  dilated  that  it  measured  35  cm.  in 
circumference.  The  caecum  was  even  more  dilated  and  was  the  size 
of  a  child's  head.     In  one  of  my  cases  of  periodical  accumulation  of 

1  Gaz.  hebd.,  No.  28,  1858. 


ENTERO-LITHIASIS.—F^CAL   OBSTRUCTION.  77 

faeces  in  the  sigmoid  flexure,  the  patient  would  only  return  for  treat- 
ment at  a  time  when  symptoms  of  obstruction  set  in,  and  every  time 
he  presented  himself  the  swelling  would  occupy  almost  the  entire 
space  in  the  abdomen  below  the  umbilicus.  Mechanical  removal  of 
the  faecal  accumulation  followed  by  massage  and  the  use  of  the  Far- 
adic  current  and  galvanism  had  no  eflPect  in  diminishing  the  size  of 
the  bowel,  or  in  preventing  the  periodical  accumulation  of  faeces.  If 
the  caecum  alone  is  the  seat  of  impaction  it  often  presents  the  appear- 
ance of  a  circumscribed  tumor  which  may  be,  and  has  been  mistaken 
for  an  ovarian  tumor,  abscess  or  carcinoma.  The  retained  mass  con- 
stitutes an  irritant  which  sooner  or  later  causes  a  catarrhal  enteritis, 
which  extends  to  the  remaining  tunics  and  is  often  the  direct  cause 
of  perforation  or  difPuse  peritonitis.  In  some  instances  the  inflamma- 
tion extends  to  the  connective  tissue  around  the  intestine  and  an 
abscess  forms  without  an  antecedent  perforation.  The  distended 
bowel  gradually  becomes  paretic  and  the  local  and  general  symp- 
toms are  aggravated. 

One  of  the  most  important  diagnostic  points  is  to  make  pressure 
over  the  tumor  in  chloroform  narcosis,  when  the  faecal  masses  become 
displaced,  leaving  a  permanent  depression  at  the  point  of  pressure. 
If  the  impaction  is  within  reach  the  removal  should  be  accomplished 
by  the  use  of  a  scoop,  assisted  by  copious  injections.  If  the  bowel  at 
the  seat  of  impaction  has  lost  its  contractility  the  use  of  cathartics  is 
useless,  and  if  it  is  in  a  state  of  inflammation,  positively  hurtful.  In 
such  cases  massage  and  high  injections  are  indicated.  Perforation 
and  suppurative  inflammation  in  the  connective  tissue  surrounding 
the  bowel  must  be  met  by  prompt  surgical  treatment.  In  cases 
where  all  ordinary  measures  fail  in  removing  the  f ascal  accumulation 
and  the  symptoms  of  obstruction  continue  unabated,  it  would  be  not 
only  justifiable,  but  good  surgery,  to  cut  down  upon  the  distended 
bowel  and  to  break  up  the  mass  within  the  gut  and  push  it  along  to 
a»  portion  of  the  intestine  where  peristaltic  action  has  not  been 
impaired.  In  cases  where  the  intestinal  wall  presents  pathological 
conditions  which  woidd  contra-indicate  such  a  course  of  treatment, 
it  may  become  necessary  to  resort  to  enterotomy  and  remove  the 
faecal  mass  through  the  wound,  and  according  to  circumstances  either 
close  the  visceral  wound  by  suturing,  or  establish  a  temporary 
artificial  anus  in  one  of  the  inguinal  regions. 


78  INTESTINAL  SURGERY. 

2.     Invagination. 

Treves'  asserts  that  thirty  per  cent,  of  all  forms  of  intestinal 
obstruction,  exclusive  of  hernia  and  congenital  malformations,  are 
cases  of  invaginatioii.  The  same  author  recognizes  clinically  four 
forms.  The  ultra-acute  is  very  rare,  and  terminates  fatally  in  twenty- 
four  hours  ;  the  acute,  lasting  from  two  to  seven  days,  numbered 
about  forty-eight  per  cent,  of  all  cases  of  invagination;  thesubacute, 
lasting  from  seven  to  thirty  days,  are  about  thirty- four  per  cent. ;  and 
the  chronic,  lasting  over  thirty  days,  occurred  about  eighteen  times 
out  of  every  one  hundred  cases.  As  far  as  the  operative  treatment 
is  concerned  it  is  exceedingly  important  to  classify  all  cases  into 
acute  and  chronic,  as  in  the  former  class  the  symptoms  appear  with 
great  violence,  and  the  pathological  changes  at  the  seat  of  invagina- 
tion come  on  so  rapidly  that  death  is  inevitable,  unless  efficient 
surgical  treatment  is  resorted  to  before  the  tissues  at  the  seat  of 
invagination  have  undergone  changes  incapable  of  repair.  In  the 
chronic  form  the  symptoms  are  never  so  urgent  and  the  adoption  of 
early  radical  measures  is  not  so  urgently  indicated.  Of  the  anatom- 
ical forms,  in  the  cases  collected  by  Treves,  thirty  per  cent,  were 
enteric;  eighteen,  colic;  forty-four,  ileo-csecal;  and  eight,  ileo-colic. 
The  enteric  forms  are  most  connnon  at  the  lower  part  of  the  jejunum, 
and  are  small.  The  colic  forms  are  mostly  to  the  left  of  the  trans- 
verse colon.  The  latter  as  a  ride  belong  to  the  chronic  form  of 
invagination. 

Leichtenstern^  calls  an  invagination  ileo-csecal  when  the  ileo- 
csecal  valve  is  pushed  forward  and  forms  the  apex  of  the  intussuscep- 
tum ;  ileo-colonic  when  the  ileum  is  pushed  through  the  valve.  The 
invagination  always  increases  at  the  expense  of  the  intussuscipiens. 
In  examining  four  hundred  and  seventy-nine  cases  of  invagination 
in  reference  to  the  anatomical  location  of  the  lesion  he  gives  the 
following  figures: 

Ileo-caecal 212 

Ileum 142 

Colon 86 

Ileo-colonic 39 

479 

1  The  Lancet,  December  13,  1884. 

^Ueber  Darm-Invagination.  PragerVierteljahrsschrift  f.  Heilkunde.  B.  II 
■a.  in,  1873. 


INVAGINATION.  79 

'  I  shall  not  endeavor  to  elaborate  upon  the  views  entertained  by 
different  authors  and  experimenters  concerning  the  mechanism  of  the 
ordinary  forms  of  invagination,  but  from  a  surgical  aspect  it  is  impor- 
tant to  allude  to  some  of  the  pathological  conditions  which  produce 
the  invagination,  and  at  the  same  time  complicate  the  treatment. 
Mr.  Bellamy '  has  described  a  case  of  a  very  rare  form  of  intestinal 
obstruction,  due  to  invagination  of  a  portion  of  small  intestine  in 
the  walls  of  the  rectum,  successfully  treated  by  abdominal  section. 
The  obstruction  had  been  complete  for  nine  days.  The  patient  was 
a  female  who  had  been  subject  to  obstinate  constipation,  and  on 
three  occasions  the  retention  of  f  secal  matter  had  given  rise  to  serious 
symptoms,  which,  however,  had  always  yielded  to  ordinary  means. 
On  admission  into  the  hospital  a  hard  swelling  could  be  felt  in  the 
left  iliac  fossa,  in  the  region  of  the  inguinal  canal  and  sigmoid 
flexure.  Manual  examination  of  the  rectum  disclosed  an  obstruc- 
tion in  the  upper  part  of  this  portion  of  the  intestine.  As  the 
symptoms  of  obstruction  became  urgent  and  failed  to  yield  to  ordi- 
nary treatment,  abdominal  section  was  performed  after  exploration  of 
the  left  external  inguinal  ring,  which  had  been  the  seat  of  an  old 
hernia,  by  enlarging  the  incision  upwards  and  obliquely  outwards. 
On  introducing  the  hand  into  the  abdomen  it  was  ascertained  that 
the  swelling  in  the  iliac  region  was  composed  of  a  knuckle  of  small 
intestine  which  was  obviously  invaginated  in  the  anterior  aspect  of 
the  first  part  of  the  rectum,  and  in-  addition  there  was  felt  what 
appeared  to  the  touch  to  be  bands  of  organized  lymph,  stretching 
across  in  the  same  place,  and  probably  the  result  of  a  former  circum- 
scribed peritonitis.  The  operator  introduced  his  right  hand  into  the 
rectum  and  pushed  the  prolapsed  mass  upwards  and  towards  his  left 
hand,  which  was  in  the  pelvic  cavity,  at  the  same  time  breaking  down 
the  adhesions  and  gently  drawing  out  the  knuckle  from  its  imprisoned 
position,  and  freeing  it  from  the  peritoneal  fold.  The  symptoms  of 
obstruction  subsided  promptly  and  the  patient,  after  having  passed 
through  a  moderate  attack  of  peritonitis,  made  a  complete  recovery. 

'  In  examining  the  literature  of  the  subject  the  author  had  been 
unable  to  find  any  case  where  abdominal  section  had  been  performed 
for  a  similar  condition,  although  Lockhart  described  this  form  of 
hernia,  but  he  stated  that  he  had  never  known  an  operation  neces- 

1  British  Medical  Journal,  March  8,  1879. 


80  INTESTINAL  SURGERY. 

sary.  The  cause  of  a  chronic  invagination  is  often  a  tumor  attached 
to  the  inner  surface  of  the  bowel.  The  tumor  by  its  weight  drags 
the  portion  of  intestine  to  which  it  is  attached,  into  the  segment  of 
bowel  below,  and  the  descent  of  the  intussusceptum  is  often  very 
slow.  In  these  cases  the  tumor  is  always  found  attached  to  the 
apex  of  the  intussusceptum.  Invagination  caused  by  tumors  is  most 
frequent  in  the  large  intestine,  as  this  is  more  frequently  the  seat 
of  invagination  than  the  intestinal  canal  above  the  ileo-csecal  valve. 
Tuffier*  reports  a  case  of  invagination  operated  on  by  Marchand 
which  is  of  special  interest  on  account  of  the  rare  condition  found 
which  had  led  to  the  invagination. 

The  patient  was  a  woman  forty-three  years  of  age,  who  had 
suffered  from  a  gradually  increasing  intestinal  obstruction.  Rectal 
examination  revealed  a  tumor,  which  had  dragged  an  upper  segment 
of  the  bowel  with  it  into  the  rectum.  Marchand  opened  the  abdo- 
men in  the  left  inguinal  region  and  found  an  invagination  of  the 
sigmoid  flexure  into  the  rectum.  Reduction  was  found  impossible. 
An  artificial  anus  was  established  after  the  method  of  Littr6.  Death 
on  the  fifth  day.  The  necropsy  showed  diffuse  peritonitis,  which  in 
the  small  pelvis  had  assumed  a  suppurative  type.  The  sigmoid 
flexure  was  found  invaginated  to  the  depth  of  6  cm.,  and  the 
serous  surfaces  adherent,  which  yielded  only  to  considerable  traction 
force.  A  pedunculated  lipoma  was  attached  to  the  apex  of  the 
intussusceptum. 

Kulenkampff^  reports  the  case  of  a  woman,  aged  thirty-nine 
years,  who  had  suffered  from  incomplete  obstruction  of  the  bowels 
with  bloody  discharge  from  the  anus  for  six  months.  During  the 
progress  of  the  disease  a  mass  could  be  felt  in  the  rectum,  which 
was  thought  to  be  a  polypus.  This  proved  to  be  a  papilloma  (prob- 
ably malignant)  that  originated  in  the  sigmoid  flexure,  and  had 
been  the  cause  of  the  invagination  of  that  part  of  the  colon  into  the 
rectum.  The  entire  mass,  including  the  intussusceptum,  was  removed 
through  the  rectum.  An  adherent  coil  of  intestine  was  accidentallv 
wounded  and  the  woimd  was  at  once  closed  by  suturing.  The 
operation  was  followed  by  an  aggravation  of  symptoms  of  obstruc- 
tion, and  on  the  tenth  day  laparotomy  had  to  be  performed,  and  an 

^  Invagination  de  1'  iliaque  dans  le  rectum.     Laparotomie  laterale.     Anus 
de  Littr6.     Lipome  de  1'  intestin.     Le  Progrfes  M6dical,  1882,  p.  202. 
2  Centralblatt  f .  Chirurgie,  No.  47,  1886. 


INVAGINATION.  .  81 

artificial    anus    was    established   in   the   left    groin.       The    patient 
recovered,  but  the  fsecal  fistula  remained. 

Bryant '  related  the  case  of  a  lady,  aged  seventy-four,  who  had 
been  suffering  from  obstruction,  due  to  invagination,  for  fourteen 
days.  He  suspected  the  existence  of  a  growth,  and  this,  after  much 
difficulty,  was  found,  drawn  down  and  removed,  the  patient  making 
a  rapid  and  perfect  recovery. 

Barker,^  in  a  case  of  invagination  of  the  rectum,  due  to  adenoid 
epithelioma  of  that  part  of  the  gut,  succeeded  in  drawing  down  and 
excising  the  affected  part,  and  reduced  the  invagination.  The  patient 
recovered  completely.  Three  similar  cases  had  been  treated  previ- 
ously in  the  same  manner,  two  by  Verneuil,  and  one  by  Kulen- 
kampft',  only  one  of  them  recovering. 

The  case  reported  by  Nicolaysen^  is  of  special  interest  as  illus- 
trating the  course  to  be  pursued  when  it  becomes  necessary  to  resect 
a  portion  of  the  intestine  with  the  tumor.  The  patient  was  a  woman 
forty-nine  years  old,  who  had  suffered  from  troublesome  constipa- 
tion and  painful  defecation  for  a  year,  due  to  chronic  invagination 
of  the  sigmoid  flexure  of  the  colon  into  the  rectum,  produced  by  an 
epithelioma.  Through  the  rectum  a  tumor  could  be  felt  which  by 
traction  could  be  drawn  down  to  the  anus.  The  diasrnosis  made 
was  carcinoma  of  the  colon  and  invagination  of  colon  into  rectum. 
The  patient  could  produce  the  invagination  at  will.  The  extirpation 
was  made  by  pulling  the  tumor  downwards  beyond  the  anal  orifice. 
The  healthy  mucous  surfaces  2.5  cm.  above  the  base  of  the  tumor 
were  circumscribed  by  a  row  of  silk  sutures,  which  were  carried 
through  the  entire  thickness  of  both  intestinal  walls.  The  tumor 
was  excised  one  cm.  below  the  sutures;  only  one  artery  had  to  be 
tied.  Posteriorly  and  on  the  left  side  of  the  circular  wound  the 
divided  meso-colon  could  be  seen.  The  wound  was  accurately  united 
by  a  superficial  continued  suture.  As  soon  as  the  bowel  was  replaced 
it  retracted  as  far  as  the  upper  portion  of  the  rectum.  The  patient 
had  recovered  after  fifteen  days  and  reported  herself  well  at  the 
end  of  two  and  a  half  months.     The  intestinal  tube  removed  meas- 

'  British  Medical  Journal,  April  9,  1887, 
2  The  Lancet,  May  14,  1887. 

^  Tumor  carcinomatosus  intestini  S.  romani:  Resektion  af  S.  romanum; 
Heltredelse.  Nord.  Med.  Arkiv.  B.  XIV,  No.  13. 


82  INTESTINAL  SURGERY. 

iired  6.5  cm.       The  tumor  under  the  microscope  showed  the  typical 
structure  of  cylindrical-celled  epithelioma. 

Becker'  has  collected  a  number  of  cases  from  the  literature, 
where  the  cause  of  the  invagination  was  a  diverticulum  of  the  small 
intestine,  and  he  believes  that  some  of  the  reported  cases  of 
elimination  of  portions  of  the  intestine  with  the  appendix  vermi- 
formis  were  of  this  kind,  and  that  in  these  cases,  what  appeared  as 
the  appendix  was  in  reality  a  diverticulum. 

The  mechanical  disturbances  at  the  seat  of  invagination  are 
sometimes  the  cause  of  an  additional  obstruction.  In  one  of  Dent's 
cases  in  a  child  six  months  old,  who  for  three  days  before  admission 
into  St.  George's  Hospital  had  sufiPered  from  evident  intussusception, 
the  abdominal  section  revealed  a  two-fold  cause  for  the  obstruction, 
invagination  and  internal  strans^ulation.  When  the  abdomen  was 
opened  a  loop  of  bowel  was  found  constricted  by  the  sharp  edge  of  a 
piece  of  mesentery  of  the  ileum  which  was  invaginated  into  the 
Ccecum.  The  band  was  divided  and  the  invagination  easily  reduced. 
Peritonitis  had  set  in  before  the  operation,  and  the  child  died  in  live 
hours  after  it.  This  case  should  remind  us  to  look  for  additional 
causes  of  obstruction  around  the  site  of  the  invagination  in  all  cases 
where  the  abdomen  is  opened  in  the  treatment  of  intussusception. 
Similar  care  should  be  exercised  under  the  same  circumstances  after 
the  reduction  has  been  accomplished,  to  look  for  an  additional 
invagination,  as  cases  have  been  reported  where  two  or  more 
invaginations  were  present  at  the  same  time. 

Claudot^  has  given  an  accurate  description  of  a  specimen  of 
double  invagination  in  a  patient  who  had  died  with  symptoms  of 
intestinal  obstruction.  The  first  invagination  was  80  cm.  below  the 
pylorus,  the  second  two  metres  further  down ;  the  latter  consisted  of 
an  invagination  of  the  ileum  into  the  colon,  the  intussusceptum 
having  advanced  nearly  the  entire  length  of  the  ascending  colon. 
The  upper  invagination  showed  evidences  of  gangrene,  of  Avhich  no 
signs  could  be  seen  in  the  lower,  and  for  this  reason  it  is  probable 
that  the  upper  invagination  occurred  first.  Intestinal  hsemorrhage 
was  one  of  the  prominent  symptoms  during  life  in  this  case. 

At  a  meeting  of  the  Pathological  Society  of  London,  Power' 

^  Zur  Aetiologie  der  Darmeinschiebung.     Dissertation.     Kiel,  1885.. 
2  De  rocclusion  intestinale.     Thfese,  Paris,  1884. 
^  Transactions,  vol.  XX,  page  240. 


PATHOLOGY  OF  ACUTE  INVAGINATION.  83 

demonstrated  a  specimen,  obtained  from  a  child  five  months  old,  of 
double  intussusception,  one  in  the  ileo-csecal  region  two  inches  in 
length,  the  other  in  the  transverse  colon,  one  inch  in  length.  The 
latter  was  an  ascending  invagination.  Both  invaginations  showed 
adhesions  between  the  serous  siirfaces,  and  consequently  must  have 
been  ante-mortem  conditions. 

In  regard  to  the  age  of  patients  suffering  from  invagination,  it 
can  be  said  that  fiftj^per^ent.  of  all  cases  occurred  in  persons  tmder 
ten  years  of  age.  Invagination  in  children,  according  to  Heusner, 
is  the  cause  of  obstruction  in  three-fourths  of  all  cases  of  intestinal 
obstruction.  If  all  cases  of  invagination  were  tabulated  it  would  be 
seen  that  one -fourth  of  the  whole  number  would  be  children  under 
one  year  of  age.  The  acute  form  is  most  frequent  in  the  young,  and 
the  chronic  variety  between  the  ages  of  twenty  and  forty. 

Leichtenstern  ^  has  studied  the  mortality  which  attends  invagi- 
nation, and  in  five  hundred  and  fifty-seven  cases  in  which  the  termi- 
nation was  known  the  result  was  as  follows: 


Mortality  of  Cases 
Without  Elimination 
Age.  Total  Mortality.  of  Gangrenous  Portion. 

1  Year 88  )  „„ 

2  Years 82  ( ®^ 


2-10  '•  72      80 

11-20  "  63      86 

21-40  "  63      82 

41-50  "  63 


51-60        "      71  i ^^ 

More  than  60  years 77 

From  this  table  it  can  be  seen  that  the  mortality  up  to  the  age 
of  forty  increases  with  the  diminution  of  the  age  of  the  patients, 
being  greatest  in  infants  and  children,  in  whom  the  invagination 
usually  pursues  an  acute  course. 

Pathology  of  Acute  Invagination. 

The  pathological  changes  in  the  acute  form  of  invagination  are 
chiefly  of  two  kinds:  1.  Obstruction  of  the  bowel;  2.  Strangulation 
of  the  intussusceptum.  Both  of  these  results  may  be  absent  in  the 
chronic  form.  The  obstruction  is  due  not  only  to  the  narrowing 
of  the  lumen  of  the  bowel  by  the  invagination,  but  also  to  the 
swelling  of  the  invaginated  portion,  caused  by  the  constriction  of 
the  blood  vessels  supplying  the  intussusceptum  at  the  neck  of  the 

1  Ueber  Darminvagination,  III,  Theil.    Prager  Vierteljahrsschrift  f.  Heil- 
kunde,  B.  CXX,  p.  17. 


84  INTESTINAL  SURGERY. 

intussuscipiens.  In  cases  of  chronic  invagination  where  no  such 
vascular  engorgement  is  present  the  lumen  of  the  intussusceptum 
remains  sufficiently  large  for  a  free  passage  of  the  intestinal  contents, 
and  no  symptoms  of  obstruction  are  observed.  In  a  niimber  of  my 
experiments  on  animals  where  I  produced  invagination  artificially,  no 
symptoms  of  obstruction  were  observed,  and  when  the  animals  were 
killed  weeks  or  months  after  the  invagination  had  been  made,  the 
lumen  of  the  intussusceptum  was  not  larger  than  an  ordinary  lead 
pencil,  and  yet  the  bowel  on  the  proximal  side  was  not  dilated,  but 
somewhat  hypertrophic.  The  greatest  danger  after  invagination  has 
taken  place  arises  from  the  constriction  of  the  intussusceptum  at  the 
neck  of  the  intussuscipiens.  The  acuity  of  the  symptoms  are  always 
proportionate  to  the  severity  of  the  strangulation  at  this  point.  The 
circular  constriction  interferes  with  the  return  of  venous  blood  from 
the  intussusceptum,  which  is  followed  by  cedema,  complete  stasis  and 
gangrene  of  the  constricted  portion.  An  acute  invagination  becomes 
irreducible  by  ordinary  means  within  a  few  hours,  on  account  of  the 
appearance  of  oedema  in  the  intussusceptum.  If  the  strangulation 
is  less  intense  the  passive  congestion  precedes  a  plastic  inflammation 
of  the  serous  surfaces  held  in  apposition,  and  adhesions  form  which 
again  oppose  or  render  a  reduction  impossible.  In  cases  where 
gangrene  of  the  invaginated  portion  follows  a  few  hours  or  days 
after  the  invagination,  no  adhesions  form  between  the  serous  surfaces. 
Adhesions  at  the  neck  of  the  intussuscipiens  and  throughout  the 
extent  of  the  invagination  may  form  soon  and  they  may  be  absent 
after  six  weeks,  in  the  chronic  variety.  Adhesions  are  met  with  in 
about  eighty  per  cent,  of  chronic  cases,  and  forty  per  cent,  of  acute 
ones.  In  acute  cases  a  fatal  termination  usually  takes  place  from 
perforation  at  the  neck  of  the  intussuscipiens  followed  by  septic 
peritonitis. 

Numerous  cases  have  been  reported  where  a  spontaneous  cure 
was  effected  by  sloughing  and  elimination  of  the  intussusceptum. 
This  favorable  termination  is  only  possible  if  the  continuity  of  the 
intestine  is  restored  at  the  neck  of  the  intussuscipiens  by  firm  unyield- 
ing adhesions,  before  the  proximal  end  of  the  intussusceptum  has 
become  gangrenous,  or  if  the  line  of  demarcation  is  below  the  neck. 
Gangrene  usually  commences  at  the  apex  of  the  intussusceptum  and 
travels  in  the  direction  of  the  neck.  That  sloughing  and  elimination 
of  the  intussusceptum  are  not  always  followed  by  recovery  becomes 


PATHOLOGY   OF  ACUTE  INVAGINATION.  85 

evident  from  a  study  of  one  hundred  and  forty-nine  such  cases  col- 
lected by  Leichtenstern.  Out  of  this  number  sixty-one  died  and 
eighty-eight  recovered,  a  mortality  of  forty-one  per  cent.  Separa-^ 
tion  of  the  gangrenous  intussusceptum  usually  takes  place  in  acute 
cases  from  tM~eleventh  to  the  twenty-first  day,  and  in  children 
somewhat  earlier  than  in  adults.  The  length  of  the  slough  corre- 
sponds with  the  length  of  the  invaginated  portion,  and  cases  are  on 
record  where  recovery  followed  after  the  elimination  of  five  or  six 
feet  of  intestine.  According  to  Treves,  spontaneous  elimination  takes 
place  in  about  forty  per  cent,  of  all  cases.  The  frequency  with 
which  it  takes  place  in  the  different  anatomical  forms  varies,  being 
twenty  per  cent,  in  the  ileo-caecal  form,  twenty-eight  per  cent,  in 
the  colic  form,  and  sixty-one  per  cent,  in  the  enteric  form,  so  that  it 
is  most  rare  in  the  most  common  form.  Frequency  of  elimination 
also  increases  with  the  age  of  the  patient,  being  least  common  in 
infants  on  account  of  the  rapidly  fatal  course  of  the  disease  in  them, 
and  most  frequent  in  patients  advanced  in  life. 

Birch-Hirschfeld^  gives  an  accurate  post-mortem  description  of 
a  child  two  years  of  age,  which  had  recovered  from  a  doiable  invagi- 
nation by  sloughing  and  elimination  of  the  intussuscepta,  and  died 
four  months  later  of  measles.  At  the  necropsy  it  was  found  that 
the  lower  portion  of  the  ileum,  the  c?ecum  and  appendix  vermiformis 
were  absent.  A  circular  cicatrix  in  the  lumen  of  the  gut  showed 
where  separation  had  taken  place ;  upon  the  serous  surface  at  the 
same  point,  a  circular  depression  indicated  the  site  where  separation 
had  occurred.  The  second  invagination  had  evidently  been  in  the 
colon  at  the  junction  of  the  ascending  with  the  transverse  portion, 
as  a  similar  cicatrix  was  also  found  in  this  locality.  The  cures 
after  spontaneous  elimination  of  the  intussusceptum  are  often  more 
apparent  than  real,  as  such  an  ideal  restoration  of  the  intestinal 
canal  as  that  described  by  Birch-Hirschfeld  is  but  rarely  effected. 

Kuettner^  has  followed  up  the  history  of  several  of  these  cases 
and  has  found  that  not  an  inconsiderable  number  of  them  die  later 
from  perforation  and  peritonitis.  Stricture  of  the  intestine  has  also 
been  observed  as  a  sequela  in  some  of  these  cases, 

1  Fall  von  Geheilten  Invaginationen  des  Darmes.     Archiv.  der  Heilkunde, 
Heft  1,  1869,  p.  108, 

2  Drei  Falle  von  Intussusception  und  deren  praesumptive.     Heilung.    Vir- 
chow's  Archiv.,  B.  53,  p.  274, 


86  INTESTINAL  SURGERY. 

Gerry'  reports  such  a  case.  The  invagination  was  acute,  and 
after  three  weeks  a  portion  of  the  small  intestine,  seventeen  and  a 
half  inches  in  length,  passed  per  anum,  followed  later  by  a  number 
of  smaller  fragments.  Soon  after  the  apparent  recovery  had  taken 
place,  symptoms  of  obstruction  again  set  in,  due  to  the  formation  of 
a  stri»3ture  at  the  point  where  spontaneous  resection  had  taken  place, 
from  the  efPects  of  which  the  patient  died,  seven  months  after  the 
invagination.  At  the  necropsy  a  circular  stricture  was  found  in  the 
upper  part  of  the  small  intestine  with  loss  of  several  feet  of  the 
intestine  by  sloughing,  a  fistulous  communication  between  the  small 
intestine  and  the  descending  colon,  and  chronic  peritonitis. 

Pathology  of  Chronic  Invagination. 

In  cases  of  chronic  invagination  the  symptoms  are  identical  with 
those  of  intestinal  stenosis  from  other  causes.  The  constriction  at 
the  neck  of  the  intussuscipiens  is  not  suflficient  in  degree  to  arrest 
the  circulation  in  the  invaginated  portion,  consequently  gangrene 
does  not  take  place.  The  seat  of  the  invagination  and  the  bowel  on 
the  proximal  side  become  the  seat  of  hyperplastic  changes,  from  the 
chronic  congestion  which  attends  the  lesion,  and  from  the  increased 
peristalsis  which  is  maintained  by  the  chronic  obstruction. 

Pohl"  has  described  an  interesting  specimen  of  chronic  invagi- 
nation taken  from  a  man  sixty-two  years  of  age,  who  suffered  from 
two  attacks  of  intestinal  obstruction  eleven  years  apart.  The  second 
attack  proved  fatal  after  an  illness  of  eleven  days.  The  post-mortem 
appearances  indicated  that  the  invagination  which  was  found  had 
existed  for  eleven  years,  and  that  the  second  attack  was  due  to  an 
aggravation  of  the  mechanical  difficulties  at  the  seat  of  invagination, 
which  had  given  rise  to  ulcerative  mflammation  of  the  mucous  mem- 
brane lining  the  intussusceptum,  perforation  and  suppurative  peri- 
tonitis. The  intussusception  was  located  in  the  lower  portion  of 
the  ileum.  The  intussuscipiens  was  30  cm.  in  length,  its  muscular 
coat  hypertrophic,  mucous  membrane  thickened  and  very  vascular, 
and  some  of  its  folds  adherent  to  the  enclosed  intestine  ;  on  the 
posterior  wall  near  the  mesenteric  attachment  two  perforations  were 
found.      The  intussusceptum  was  24  cm.   in  length,  and  its  mucous 

^  A  Case  of  Intussusception.     Boston  Medical  Journal,  No.  25,  1877. 
2  Ueber  den  Befund  einer  durch  viele  Jahre  getragene  Darm-Intussuscep- 
tion.     Prager  Med.  Wochenschrift,  No.  21, 1884. 


CHRONIC  INVAGINATION.— TREATMENT.  87 

membrane  extensively  ulcerated;  old  and  firm  adhesions  at  the  neck 
of  the  intussuscipiens.  The  mesentery  of  the  ileum,  throughout, 
but  especially  at  the  seat  of  invagination,  much  thickened.  Ileum 
above  obstruction  dilated  and  its  walls  thickened. 

Leichtenstern '  reports  a  case  of  chronic  invagination  which 
presents  a  number  of  interesting  points.  The  attack  was  brought  on 
by  indiscreet  diet  and  was  attended  by  well-marked  symptoms, 
tenesmus,  liquid  stools  mixed  with  mucus  and  blood.  The  patient 
lived  for  eleven  weeks.  After  the  first  few  days  the  stools  were 
normal  in  size  and  consistence.  Eecurring  colicky  pains,  often  very 
severe,  constituted  the  most  troublesome  and  important  symptom. 
A  swelling  in  the  region  of  the  transverse  colon  could  always  be  felt, 
but  became  firmer  and  more  circmnscribed  during  the  attacks  of 
colic  or  after  a  prolonged  examination  by  palpation.  The  necropsy 
revealed  an  ileo-csecal  invagination,  the  lowest  portion  of  which  con- 
sisted of  the  point  of  entrance  of  the  ileum  into  the  colon,  the  inner 
cylinder  of  the  csecum  and  ascending  colon,  and  the  outer  cylinder 
or  sheath  of  the  transverse  colon.  All  of  the  parts  involved  in  the 
invagination  were  the  seat  of  hypertrophic  changes. 

Treatment. 

Early  recognition  of  the  existence  of  invagination  is  of  the 
greatest  importance  for  successful  treatment,  as  the  prospects  for 
successful  reduction  by  ordinary  surgical  means  diminish  with  the 
development  of  secondary  pathological  conditions  at  the  seat  of 
invagination.  Many  of  the  artificial  invaginations  Avhicli  I  made  in 
animals  were  reduced  spontaneously  within  a  few  hours,  and  in 
order  to  study  the  effects  of  invagination  I  had  finally  to  resort  to 
suturing  at  the  neck  of  the  intussuscipiens  in  order  to  permanently 
retain  the  invaginated  portion.  Reduction  was  resisted  after  a  time 
either  by  the  swollen,  oedematous  intussusceptum  or  by  the  adhesions 
at  the  neck  of  the  intussuscipiens,  or  between  the  serous  surfaces 
throughout  the  invaginated  portion  of  the  bowel.  From  these 
observations  I  have  come  to  the  conclusion  that  reduction  by  gentle 
but  efficient  distention  of  the  bowel  below  the  invagination  would 
succeed  in  the  majority  of  cases,  if  this  procedure  were  practiced 
before  either  of  the  two  principal  conditions  which  cause  irreduci- 

'  Dai-m-Iiivagination  von  monatlicher  Dauer.  Deutsches  Archiv.  f .  Klin, 
Medicin,  B.  XII,  p.  381. 


88  INTESTINAL  SURGERY. 

bility  have  had  time  to  make  their  appearance.  As  soon  as  the 
existence  of  an  invagination  is  suspected  the  large  intestines  should 
be  emptied  of  their  contents  by  the  administration  of  a  large  enema, 
the  patient  being  kept  in  Hegar's  position.  After  this  has  been 
done  the  patient  should  be  placed  thoroughly  under  the  influence  of 
an  anaesthetic  so  as  to  facilitate  the  next  step  in  the  treatment: 

Rectal  Insufflation  of  Hydrogen  Gas. 

As  gas  can  be  readily  forced  beyond  the  ileo-csecal  valve,  this 
method  of  treatment  is  applicable  in  the  treatment  of  invagination 
in  any  portion  of  the  intestinal  canal,  and  as  distention  of  the  intes- 
tine below  the  seat  of  obstruction  may  prove  successful  in  correcting 
the  mechanical  difliculties  due  to  other  causes,  it  should  be  resorted 
to  both  as  a  diagnostic  and  therapeutic  measure  in  the  beginning 
of  all  cases  of  intestinal  obstruction,  in  which  a  positive  diagnosis  of 
other  forms  of  obstruction  cannot  be  made  without  it.  The  modus 
operandi  of  this  surgical  resource  I  witnessed  in  an  animal,  on 
the  third  day  after  the  invagination  had  been  made,  by  opening  the 
abdomen  and  exposing  to  sight  the  seat  of  invagination  before  the 
insufflation  was  made.  In  this  instance  two  inches  of  the  ileum 
were  invaginated  into  the  colon  and  fixed  by  two  fine  silk  sutures  at 
the  neck  of  the  intussu.scipiens.  On  the  third  day  the  abdominal 
cavity  was  re-opened  by  an  incision  along  the  outer  border  of  the 
right  rectus  muscle,  and  the  invaginated  bowel  drawn  forward  into 
the  wound.  The  bowel  at  point  of  operation  was  very  vascular,  and 
the  neck  of  the  intussuscipiens  covered  with  plastic  exudation.  The 
sutures  were  removed  and  the  rectum  and  colon  distended  with  gas 
for  the  purpose  of  effecting  reduction.  As  soon  as  the  colon  had 
become  thoroughly  distended,  the  adhesions  which  had  formed  gave 
way  with  an  audible  noise,  and  complete  reduction  followed  in  such 
a  manner  that  the  part  last  invaginated  was  first  released.  As  the 
force  necessary  to  rupture  the  adliesions  and  to  reduce  the  bowel 
produced  no  injury  of  any  kind  to  the  intestine  below  or  at  the  seat 
of  invagination,  this  experiment  would  tend  to  prove  that  insufflation 
can  be  practiced  successfully  in  cases  of  invagination  of  several 
days'  duration. 

The  rectal  insufflation  of  hydrogen  gas  in  the  reduction  of  an 
invagination  should  always  be  made  under  the  influence  of  an  anaes- 
thetic administered  to  the  extent  of  comjilete  muscular  relaxation. 


RECTAL   INSUFFLATION.— COLOTOMY.  89 

The  pressure  upon  the  rubber  balloon  should  be  uninterrupted  and 
should  never  exceed  two  pounds  to  the  square  inch.  Disinvagina- 
tion  is  effected  by  inflation  by  two  distinct  forces.  In  the  first  place, 
the  steady  elastic  pressure  of  the  gas  distends  the  bowel  between  the 
sheath  and  the  returning  cylinder,  which  makes  traction  upon  the 
neck  of  the  intussuscipiens,  while  the  column  of  gas  by  its  pressure 
against  the  apex  of  the  intussusceptum  acts  as  a  direct  reduction 
force.  In  order  to  accomplish  the  desired  mechanical  effect  the  infla- 
tion must  be  made  slowly  and  continuously,  as  when  this  is  done, 
there  is  less  danger  of  rupturing  the  bowel  than  when  rapid  inflation 
is  made  under  the  same  pressure  but  with  interruptions,  and  the 
object  of  the  inflation  is  more  surely  realized.  The  return  of  the 
gas  is  prevented  most  effectually  by  an  assistant  pressing  the  mar- 
gins of  the  anus  against  the  rectal  tube.  A  small  gutta-percha  female 
syringe  makes  the  best  rectal  tube.  A  sudden  diminution  of  pressure 
indicates  either  that  disinvagination  has  been  effected  or  that  a  rup- 
ture of  the  intestine  has  occiirred.  It  is  exceedingly  important  that 
the  surgeon  should  satisfy  himself  of  the  existence  of  a  rupture  if 
this  accident  has  occurred.  The  best  way  to  recognize  the  accident 
is  to  continue  the  inflation  under  a  pressure  of  not  more  than  a  quar- 
ter to  half  a  pound  to  the  square  inch.  If  the  invagination  has  been 
reduced  the  intestine  cbove  it  will  become  gradually  distended  by  the 
gas,  and  the  distention  takes  place  first  over  the  middle  of  the  abdo- 
men and  above  the  pubes,  ascending  gradually  as  the  inflation  is 
continued  in  an  upward  direction.  If  the  intestine  has  been  ruptured 
the  gas  escapes  into  the  peritoneal  cavity,  and  the  existence  of  the 
accident  is  proved  by  the  appearance  of  a  uniform  free  tympanites 
with  disappearance  of  liver  dullness.  In  a  recent  case  there  is  no 
danger  of  ruptiiring  the  bowel  under  a  pressure  of  two  pounds  to  the 
square  inch,  and  in  cases  where  the  tissue  of  the  intestine  yields 
under  this  pressure,  a  laparotomy  is  the  only  proper  remedy,  and  the 
occurrence  of  the  accident  renders  the  indication  for  the  performance 
of  the  operation  imperative,  without  adding  to  its  danger. 

CoLOTOMY. 

Two  indications  for  colotomy  might  arise  in  the  treatment  of 
colic  invagiilation:  1.  In  acute  cases,  when  the  general  symptoms 
are  so  grave  as  to  contra -indicate  a  laparotomy.  2.  In  irreducible 
chronic  cases,  when  the  lower  portion  of  the  colon  is  invaginated  into 


90  ■  INTESTINAL  SURGERY. 

the  upper  part  of  the  rectum,  where  it  is  impossible  to  make  a 
resection  or  anastomosis  by  lateral  apposition.  According  to  the 
location  of  the  invagination  the  operation  is  made  either  in  the  right 
or  the  left  iliac  region,  in  the  former  instance  the  opening  being 
made  in  the  csecum,  and  in  the  latter  in  the  descending  colon. 

Dubois  ^  reports  a  case  of  intussusception  where  the  invaginated 
portion  could  be  felt  in  the  region  of  the  sigmoid  flexure,  through  the 
abdominal  wall.  Colotomy  was  performed  above  the  seat  of  obstruc- 
tion, and  the  patient  not  only  recovered,  but  four  months  later  the 
permeability  of  the  intestinal  canal  was  restored  spontaneously, 
although  the  artificial  opening  had  not  closed. 

Entekotomy. 

In  irreducible  iliac  and  ileo-csecal  invagination,  an  enterotomy 
should  only  be  made  when  the  patient  is  in  such  a  collapsed 
condition  that  more  radical  measures  are  inadmissible.  As  in  the 
majority  of  cases  the  invagination  is  below  the  ileo-c?ecal  valve,  the 
artificial  opening  should  be  made  in  the  right  iliac  region.  Should 
the  invagination  be  located  higher  up  in  the  intestinal  canal,  and  an 
empty  collapsed  coil  of  intestine  present  itself  in  the  oj^ening,  it 
should  be  pushed  aside  and  search  made  for  a  distended  loop.  An 
enterotomy  is  justifiable  even  when  the  patient  is  in  an  almost 
pulseless  condition,  as  this  operation  is  attended  by  little  if  any 
shock,  as  it  can  be  done  in  a  few  minutes,  and,  if  necessary,  without 
an  anaesthetic.  Emptying  the  bowel  above  the  seat  of  obstruction 
will  bring  relief  by  removing  the  abdominal  distention,  and  by 
favorably  influencing  the  invaginated  part  by  diminishing  the  hydro- 
static pressure  above  the  obstruction,  which  in  itself  is  a  potent  cause 
in  maintaining  vascular  engorgement. 

Langenbeck^  saved  the  life  of  a  patient  suffering  from  invagina- 
tion of  the  colon,  by  an  enterotomy.  The  invagination  had  advanced 
so  far  that  the  apex  of  the  intussusceptum  could  be  felt  in  the 
rectum.  He  performed  N6laton's  operation  and  the  patient  recov- 
ered. Nine  months  after  the  operation  both  the  invagination  and 
the  artificial  anus  remained. 

'  Enterotomie  pratiquee  in  extremis.  Journ.  de  Med.  de  Bruxelles, 
December,  1878. 

^  Vorsteilung  eines  Falles  von  geheilter  Enterotomie.  Verh.  der  dentschen 
GeseU.schaft  f.  Chirurgie,  1878. 


LAPAROTOMY.  91 

Lapakotomy. 

Remembering  that  the  general  mortality  of  invagination  is 
seventy  per  cent,  and  in  children  less  than  eleven  years  of  age 
spontaneous  cure  by  elimination  of  intussusceptum  does  not  exceed 
twelve  per  cent.,  it  becomes  plain  that  in  cases  where  reduction  ie 
not  accomplished  by  rectal  inflation,  a  laparotomy  is  indicated  in  all 
instances  where  the  general  condition  of  the  patient  is  such  as  to 
justify  such  a  procedure.  It  is  true  that  the  experience  of  the  past 
in  the  operative  treatment  of  invagination  is  not  such  as  to  inspire 
confidence,  but  it  must  not  be  forgotten  that  almost  without  excep- 
tion the  abdomen  was  only  opened  as  a  last  resort,  after  the  patient 
had  been  completely  prostrated  by  the  disease,  or  after  the  invagina- 
tion had  given  rise  to  irreparable  local  conditions.  Instead  of 
discouraging  operative  interference,  the  statistics  collected  so  far 
are  the  best  possible  arguments  in  favor  of  early  operation  where 
simpler  measures  have  failed. 

Ashhurst'  brought  together,  with  more  or  less  detail,  the 
histories  of  thirteen  cases  in  which  laparotomy  has  been  undertaken 
for  the  relief  of  intussusception.  Of  this  number  five  recovered,  and 
eight  died.  As  the  result  of  a  study  of  his  cases  he  has  come  to 
the  conclusion  that  the  operation  is  not  admissible  in  patients 
less  than  one  year  of  age,  as  all  operations  up  to  that  time  done  in 
children  less  than  a  year  of  age  proved  fatal.  He  also  advises 
against  an  operation  when  the  symptoms  present,  and  particularly 
the  existence  of  intestinal  haemorrhage,  render  it  probable  that  the 
tightness  of  the  intussusception  will  lead  to  sloughing  of  the  invagi- 
nated  portion,  as  he  claims  that  under  these  circumstances  an 
operation  would  almost  surely  fail,  while  there  is  a  fair  hope  that 
separation  of  the  invaginated  mass  might  lead  to  spontaneous  recov- 
ery. Experience  has  shown  that  cure  by  spontaneous  elimination  of 
the  intussusception  seldom,  if  ever,  takes  place  in  very  young  children 
and  infants;  consequently  the  hopelessness  of  the  situation  in  such 
cases,  where  legitimate  efPorts  at  reduction  have  failed,  can  be 
advanced  as  the  most  logical  reason  in  favor  of  operative  treatment, 
as  the  patient  and  surgeon  have  nothing  to  lose  and  everything  to 
gain. 

1  Laparotomy  for  Intussusception.     Amer.  Journ.  Med.   Sciences,  July, 
1874,  p.  48. 


92  INTESTINAL  SURGERY. 

Knaggs,'  after  reporting  an  uusticcessful  case  of  abdominal 
section  for  invagination  that  occurred  in  his  own  practice,  gives  the 
results  of  thirty-seven  operations  including  his  own.  Of  this  number 
eight  recovered,  and  twenty-nine  died.  In  many  of  these  cases 
peritonitis  had  set  in  before  the  operation  was  performed,  and  this 
condition  and  not  the  operation,  was  answerable  for  the  subsequent 
fatal  issue. 

Sands  ^  has  tabulated  the  records  of  twenty-one  cases  of  lapar- 
otomy for  intussusception,  eight  of  which  have  occurred  since  the 
publication  of  Ashhurst's  paper.  Of  twenty  cases  in  which  the 
result  of  the  operation  is  given,  seven  recovered,  and  thirteen  proved 
fatal,  thus  showing  a  mortality  of  sixty-five  per  cent.  After  a  study 
of  these  cases  he  came  to  the  conclusion  that  the  prognosis  after 
operation  is  also  influenced  by  the  age  of  the  patient ;  thus,  of  twelve 
cases  of  two  years  old  or  under,  three  recovered,  and  nine  died;  of 
seven  cases  sixteen  years  old  or  over,  four  recovered,  and  three  died, 
showing  that  the  mortality  is  greater  in  infants  than  in  adults.  Sands 
remarks  very  properly  that  the  mortality  depends  more  on  the  con- 
dition of  the  intestine  than  the  age  of  the  patient.  In  taking  all 
cases  together,  he  has  found  that  the  mortality  of  the  operation  is 
fourteen  per  cent,  in  the  easy,  and  ninety-one  per  cent,  in  the  difificult 
cases.  The  largest  number  of  operations  for  invagination  has  been 
collected  by  Braun."  He  tabulated  fifty-one  operations  performed 
since  1870;  that  is,  operations  done  under  antiseptic  precautions. 
Of  this  number,  eleven  patients  were  cured,  and  forty  died.  In 
twenty-seven  of  these  cases  disinvagination  was  effected,  and  in 
twenty-four  it  was  not;  of  the  former  eighteen  were  children,  and 
nine  adults.  Four  children  recovered,  while  fourteen  died.  Seven 
adults  lived  and  two  died.  Resection  of  the  invaginated  portion  was 
practiced  twelve  times  with  only  one  recovery.  An  artificial  anus  was 
established  in  nine  cases,  followed  by  death  in  eveiy  instance. 

Treves  *  gives  the  general  mortality  in  one  hundred  and  thirty- 
three  recorded  cases  as  seventy-two  per  cent. ;  where  reduction  was 
easy  it  was  thirty  per  cent.,  and  when  difficult  ninety-one  per  cent. 
No  one  can  look  over  these  tables  without  noticing  that  the  mortality 

1  The  Lancet,  June  4,  11,  1887. 

2  New  York  Medical  Journal,  June,  1887. 

^  Verh.  der  deutschen  Gesellschaft  f.  Chirurgie,  1885. 
*  The  Lancet,  December  13, 1884. 


LAPAROTOMY.  93 

was  greatly  influenced  by  the  local  conditions,  as  when  the  reduction 
was  easy  it  was  greatly  reduced.  This  fact  alone  should  convince 
us  that  laparotomy  should  be  resorted  to  without  delay  as  soon  as  a 
faithful  attempt  at  reduction  by  rectal  insufflation  has  demonstrated 
that  reduction  cannot  be  accomplished  in  any  other  way.  The  oper- 
ation should  be  done  as  a  first,  and  not  as  a  last  resort.  As  in  cases 
of  strangulated  hernia,  the  obstacles  to  reduction  become  more 
persistent  as  time  advances,  and  the  danger  is  augmented  in  propor- 
tion to  the  time  which  elapses  until  reduction  is  attempted.  In 
reference  to  the  time  when  the  operation  should  be  done,  I  can  only 
caution  against  delay  and  make  the  positive  statement  that  it  should 
be  done  as  soon  as  it  has  been  shown  that  reduction  cannot  be 
efPected  by  rectal  insufflation.  The  age  of  the  patient  should  not 
enter  into  consideration  in  deciding  upon  the  propriety  of  an  opera- 
tion. Sands  operated  successfully  upon  an  infant  only  six  months 
old,  where  the  ordinary  treatment  by  injection  and  inflation  had 
been  only  partially  effective  in  accomplishing  disinvagination.'  The 
caecum  and  appendix  vermiformis  and  a  small  portion  of  ileum 
remained  firmly  fixed  in  the  sheath,  and  it  required  considerable 
traction  force  to  release  them. 

Godlee^  performed  abdominal  section  successfully  for  invagin- 
ation in  a  child  nine  months  old,  four  days  after  the  commencement 
of  acute  symptoms.  In  this  'case  the  invagination  had  progressed 
so  far  that  the  apex  of  the  intussusceptum  protruded  at  the  anus. 

Mr.  Hutchinson"  narrates  the  particulars  of  a  successful  abdom- 
inal section  for  intussusception  in  a  child  two  years  of  age.  The 
invagination  had  commenced  in  the  ileo-cfecal  region  and  during  the 
course  of  one  month  had  advanced  to  such  an  extent  that  the  intus- 
susceptum was  extruded  several  inches  at  the  child's  anus.  As 
rectal  injections  failed  in  reducing  the  bowel,  the  abdomen  was 
opened  by  an  incision  through  the  linea  alba  below  the  umbilicus, 
and  the  intussusceptum  was  then  easily  found,  and  as  easily  reduced. 
The  child  made  a  rapid  recovery. 

As  a  rule,  to  which  there  should  be  no  exception,  the  incision 
should  be  made  in  the  median  line,  as  it  furnishes  the  most  ready 
access  to  the  invagination,  and  enables  the  operator  to  apply  the 
various  surgical  resources  with  the  greatest  facility.     For  special 

'The  Lancet,  December  16,  1882. 
^Medical  Times  and  Gazette,  Nov.  29,  1883. 


94  INTESTINAL  SURGERY. 

indications  a  lateral  incision  can  be  made  later.  If  the  swelling  has 
not  been  previously  located  by  palpation  or  insufflation,  it  is  usually 
not  difficult  to  find  the  seat  of  obstruction.  As  soon  as  the  invag- 
inated  part  has  been  found  it  should  be  brought  into,  or  as  near  to 
the  woimd  as  possible  for  careful  examination,  as  the  future  action 
of  the  surgeon  will  be  guided  by  the  local  conditions  of  the  invag- 
inated  bowel.  If  on  examination  no  evidences  of  gangrene  are  found 
efforts  should  be  made  to  effect  reduction. 

a.     Disinvagination. 

In  recent  and  especially  acute  cases,  I  am  satisfied  that  the 
difficulties  which  resist  reduction  should  not  be  sought  in  the  presence 
of  adhesions  as  often  as  in  the  swollen  cedematous  intussusceptum. 
The  same  measures  should  be  resorted  to  to  enable  reduction  as  in 
the  preliminary  treatment  of  a  phimosis  or  paraphimosis.  The 
oedema  and  inflammatory  stvelling  should  be  removed  before  any 
efforts  (^t  reduction  are  made.  This  can  be  readily  accomplished  by 
steady  and  uninterrupted  manual  compression  of  the  invaginated 
portion.  As  soon  as  the  swelling  has  been  reduced  in  this  manner, 
reduction  is  attempted  by  making  gentle  traction  upon  the  bowel 
above  the  neck  of  the  intussuscipiens.  Should  this  fail,  inflation  is 
practiced,  and  as  soon  as  the  bowel  between  the  returning  cylinder 
and  the  sheath  has  become  expanded,  traction  is  again  made  upon 
the  upper  and  lower  ends.  If  this  maneuver  fails  to  effect  reduction, 
Rydygier's^  device  of  making  traction  above  and  pushing  from 
below  can  be  tried.  Rydygier  also  directs  that  reduction  should  be 
facilitated  by  inserting  the  finger  between  the  intussusceptum  and 
the  intussuscipiens,  for  the  purpose  of  breaking  up  adhesions.  Any 
one  who  has  had  much  experience  with  such  cases  must  have 
observed  that  the  neck  of  the  instussuscipiens  grasps  the  bowel  very 
tightly,  and  that  any  such  efforts  as  the  introduction  of  a  finger 
would  be  almost  certain  to  result  in  a  rupture  of  the  bowel.  If  the 
treatment  as  above  directed  does  not  effect  reduction  the  presence  of 
adhesions  must  be  suspected.  These  should  be  broken  up,  not  by 
the  introduction  of  the  finger,  but  by  inserting  and  passing  around 
the  bowel  a  Kocher's  director  or  a  small  probe.  When  the  adhesions 
have  been  severed,  the  efforts  at  reduction  by  traction  and  inflation 
are  repeated. 

1  Beilage,  Centralblatt  f.  Chirurgie,  1887,  p.  31. 


INTESTINAL   ANASTOMOSIS.  95 

Roser  has  suggested  that  after  reduction  has  been  effected,  the 
invagmated  portion  should  be  sutured  to  the  abdominal  wall  for 
the  purpose  of  preventing  re-invagination.  Under  proper  treatment 
it  is  not  very  likely  that  re-invagination  will  take  place,  and  such  fixa- 
tion might  subsequently  result  in  another  form  of  intestinal  obstruc- 
tion. Re-invagination  can  positively  be  prevented  by  shortening 
the  mesentery  at  the  point  of  invagination,  by  folding  it  upon  itself 
in  a  direction  parallel  to  the  bowel,  and  maintaining  it  in  this  position 
by  a  few  catgut  sutures. 

Should  repeated  attempts  at  reduction  fail,  one  of  two  courses 
of  treatment  may  be  pursued  :  1.  The  establishment  of  an  intesti- 
nal anastomosis.  2.  Resection  of  the  invaginated  portion  with  or 
without  circular  enterorrhaphy.  Resection  of  the  invaginated  por- 
tion, especially  if  the  invagination  is  extensive,  is  a  very  grave 
undertaking,  as  it  requires  a  long  time  for  its  execution,  a  matter  of 
vital  importance  in  these  cases,  and  involves  the  removal  of  impor- 
tant parts,  and  on  these  accounts  should  never  be  resorted  to  unless 
the  invaginated  parts  show  evidences  of  gangrene. 

6.   Intestinal  Anastomosis. 

An  intestinal  anastomosis  between  the  bowel  above  and  below 
the  invagination  by  decalcified  perforated  bone  discs  can  be  made  in 
fifteen  minutes,  and  at  once  restores  the  continuity  of  the  intestinal 
canal.  As  soon'  as  the  hydrostatic  pressure  above  the  obstruction  has 
been  removed  by  this  operation,  the  danger  of  gangrene  is  diminished, 
and  the  bowel  may  again  become  permeable  by  a  subsequent  spon- 
taneous reduction  or  by  elimination  of  the  intussusceptum.  If  the 
invagination  remains  permanently  it  does  no  particular  harm,  as  the 
obstructed  portion  has  be^n  excluded  by  the  anastomosis  and  subse- 
quently undergoes  atrophic  changes.  In  cases  where  the  intussus- 
ceptum has  advanced  beyond  the  sigmoid  flexure,  it  would  become 
necessary  after  ligation  to  remove  a  part  of  it  through  the  lower 
incision,  in  order  to  render  the  bowel  permeable  below  this  point.  I 
have  in  my  possession  a  number  of  beautiful  specimens  of  intestinal 
anastomosis  obtained  from  animals  in  which  I  had  made  an  artificial 
invagination,  and  subsequently  treated  them  by  making  an  intestinal 
anastomosis,  and  I  am  firmly  convinced  that  the  same  treatment  will 
prove  useful  in  practice.  , 


96  INTESTINAL  SURGERY. 

Korcynski  ^  reports  an  exceedingly  interesting  case  where  intes- 
tinal anastomosis  was  established  spontaneously  in  a  case  of  invagi- 
nation, followed  by  cure.  The  patient  was  forty-one  years  of  age, 
and  the  symptoms  of  obstruction  had  lasted  for  six  weeks  but 
were  completely  relieved  by  the  new  opening.  The  existence  of  such 
an  opening  could  be  readily  verified  by  digital  exploration  of  the 
rectum.  After  the  symptoms  of  obstruction  had  subsided,  the  exclu- 
sion of  a  part  of  the  intestinal  tract  could  be  ascertained  by  insuffla- 
tion of  the  rectum,  which  at  once  produced  a  tympanitic  distention 
of  the  middle  of  the  abdomen  without  distention  of  the  colon.  A 
similar  but  small  communication  was  found  on  post-mortem  exami- 
nation, as  in  the  case  reported  by  Gerry,  previously  referred  to. 

c.     Resection. 

The  only  indication  for  resection  is  furnished  by  gangrene  of 
the  invaginated  portion.  The  extent  of  the  gangrene  is  immaterial 
in  reference  to  the  advisability  of  making  a  resection,  as  a  small 
gangrenous  spot  necessarily  would  lead  to  perforation  and  death 
from  septic  peritonitis,  unless  this  radical  measure  were  adopted. 
The  resection  must  always  include  the  entire  intussusceptum,  but 
not  necessarily  the  entire  sheath.  The  first  evidences  of  gangrene 
upon  the  external  surface  of  the  bowel  appear  about  the  neck  of 
the  intussuscipiens.  When  the  invagination  is  extensive  and  the  lower 
portion  of  the  sheath  presents  a  healthy  appearance,  it  is  only  neces- 
sary to  resect  the  neck  of  the  intussuscipiens  and  the  intussusceptum, 
which  after  division  and  isolation  about  the  neck,  can  be  drawn  out 
and  removed.  The  bowel  above  and  below  the  proposed  points  of 
section  should  be  tied  with  a  rubber  band  to  prevent  faecal  extrava- 
sation during  the  operation.  The  mesenteric  attachments  must  be 
tied  in  small  sections  with  fine  silk  ligatures,  as  tying  in  large 
sections  or  with  catgut  is  liable  to  be  followed  by  haemorrhage. 

After  the  resection  has  been  made  it  becomes  a  serious  question 
how  to  proceed  further.  Shall  the  continuity  of  the  intestinal  canal 
be  restored  at  once  by  suturing,  or  shall  an  artificial  anus  be  estab- 
lished ?  When  the  resection  involves  the  ileum  above  and  the  colon 
below,  it  is  exceedingly  difficult  to  restore  the  continuity  of  the  intes- 
tinal canal  by  circular  enterorrhaphy,  on  account  of  the  difference  in 

^  Zwei  Falle  von   Darminvagination  langer  Dauer.     Virchow  u.  Hirsch's 
Jahr^sbericht,  B.  11,  1881,  p.  193. 


RESECTION.  97 

the  lumina  of  the  bowel  to  be  united.  As  ileo-csecal  invagination  is 
the  most  conniion  form,  it  is  evident  that,  as  a  rule,  some  other  plan 
must  be  followed.  Under  these  circumstances  one  of  two  methods 
of  procedure  can  be  chosen.  The  colon  at  the  point  of  division  is 
inverted  to  the  extent  of  an  inch  or  more,  and  closed  by  making  a 
few  stitches  of  the  continued  suture,  which  should  embrace  only  the 
serous  and  muscular, coats,  and  the  iliac  end  is  implanted  into  a  slit, 
corresponding  in  size  to  the  circumference  of  the  bowel,  made  in  the 
colon  on  the  side  opposite  to  the  meso-colon,  at  a  point  just  below 
the  closed  end.  Fixation  is  most  efficiently  secured  by  a  rubber 
ring  and  two  inversion  sutures,  to  which  should  be  added  as  a 
matter  of  precaution  a  superficial  continued  suture.  If  lateral 
implantation  cannot  be  readily  done,  an  equally  efficient  method 
consists  in  closing  both  ends  and  establishing  the  continuity  of  the 
intestinal  canal  by  lateral  apposition  with  decalcified  perforated  bone 
plates  in  the  same  manner  as  has  been  described  under  the  h^ad  of 
intestinal  anastomosis.  Restoration  of  the  continuity  of  the  intesti- 
nal canal  after  resection  of  an  invaginated  bowel  by  lateral  implan- 
tation or  lateral  apposition,  requires  much  less  time  than  a  circular 
enterorrhaphy,  while  both  operations  secure  better  conditions  for 
definitive  healing  than  circular  enterorrhaphy,  and  on  these  accounts 
should,  under  these  and  similar  circumstances,  be  preferred  to  the 
latter  procedure. 

In  cases  of  colic  invagination  requiring  an  extensive  resection, 
approximation  of  the  two  ends  is  not  possible  on  account  of  their 
distance  from  each  other  and  the  comparatively  slight  immobility 
of  this  part  of  the  intestine.  In  such  a  case  lateral  implantation 
is  impracticable  for  the  same  reasons.  The  choice  lies  between 
the  establishment  of  an  artificial  anus  and  lateral  apposition;  the 
former  should  never  be  made,  as  in  case  of  recovery  of  the  patient, 
the  faecal  fistula  would  remain  as  a  permanent  condition  without  any 
prospects  of  an  ultimate  cure.  The  continuity  of  the  intestinal  canal 
can  be  restored  at  once  in  these  cases  by  making  an  ileo-colostomy, 
or  a  colo-colostomy  by  lateral  apposition  with  perforated  decalcified 
bone  plates,  according  to  the  location  or  extent  of  the  resection. 

Wassiljew^  reports  a  very  interesting  case  of  resection  for  in- 

^  Invaginatio   ileo-caBcalis.     Laparotomia,    Resectio    intestini.      Heilung. 
Centralblatt  f.  Chirurgie,  No.  12,  1888. 


98  INTESTINAL  SURGERY. 

vagination  which  ultimately  terminated  in  recovery.  The  patient 
was  a  man,  aged  twenty-five  years,  who  was  seized  with  abdominal 
pain  and  vomiting.  As  the  symptoms  of  obstruction  did  not  yield 
to  ordinary  treatment  laparotomy  was  performed  on  the  second  day. 
On  opening  the  abdominal  cavity  a  swelling  was  readily  detected  in 
the  right  hypogastric  region.  This  swelling  was  drawn  forwards, 
and  found  to  be  an  extensive  invagination  of  the  ileum  into  the 
colon.  As  reduction  could  not  be  accomplished  an  elastic  ligature 
was  tied  around  the  gut  in  two  places  and  the  ileum  and  mesentery 
were  divided.  Then  the  invaginated  portion  was  readily  withdrawn 
and  about  seventeen  inches  were  resected.  The  abdominal  cavity 
was  washed  out  with  a  solution  of  sublimate,  and  the  cut  ends  of  the 
gut  were  fixed  by  sutures  to  the  abdominal  wound.  Much  gas  and 
fsecal  matter  escaped,  when  the  ligatures  were  united.  During  the 
sixth  week  an  operation  was  performed  for  the  cure  of  the  artificial 
anus.  About  six  inches  more  of  the  intestine  were  resected  and  the 
cut  ends  united  by  Czerny's  suture.  On  the  third  day  the  bowels 
moved,  but  on  the  fifth  day  the  fsecal  .discharges  again  escaped 
through  the  wound.  The  different  attempts  to  close  the  fistulous 
opening  failed.  Digital  exploration  showed  that  a  spur  was  begin- 
ning to  form.  To  this  spur  a  pressure  forceps  was  applied;  it  fell 
off  on  the  third  day;  ultimately  the  fistula  closed. 

3.    Volvulus. 

Volvulus  or  twisting  of  a  loop  of  intestine  around  its  axis  con- 
stitutes a  well-defined  form  of  intestinal  obstruction.  This  patho- 
logical condition  can  only  occur  where  the  mesentery  of  the  bowel  is 
of  considerable  length,  and  is  therefore  most  frequently  met  with  in 
the  lower  portion  of  the  ileum  and  at  the  sigmoid  flexure  of  the 
colon.  This  condition  as  compared  with  some  other  forms  of  intes- 
tinal obstruction  is  quite  rare.  In  fifteen  hundred  and  forty-one 
cases  of  obstruction  from  different  causes,  collected  by  Leichtenstern^ 
and  analyzed  with  special  reference  to  the  anatomical  cause  of  the 
obstruction,  after  deducting  one  hundred  and  seventy- eight  due  to 
carcinoma,  thirty-three  cases  only  were  due  to  twisting  of  the  bowel, 
this  including  twists  of  both  the  sigmoid  flexure  and  the  ileimi. 

^  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine.    Amer.  Translation, 
Vol.  III. 


VOLVULUS.  99 

Upon  another  page  the  same  author  gives  the  result  of  his  examina- 
tion of  seventy-six  cases  of  volvulus  which  he  has  collected,  and  of 
this  number  the  lesion  was  found  in  forty-five  cases  in  the  sigmoid 
flexure,  in  twenty-three  cases  in  the  ileum,  and  in  eight  cases  in  the 
jejunum  and  ileum  combined. 

,  A  simple  twist  of  a  long  loop  of  intestine  one-half  to  once 
around  its  axis  does  not  necessarily  lead  to  intestinal  obstruction. 
I  made  a  number  of  experiments  on  animals  by  rotating  a  loop  of 
intestine  from  one-half  to  twice  around  its  axis  and  keeping  it  fixed 
in  this  position  by  suturing  at  the  base  of  the  loop.  These  experi- 
ments are  interesting,  inasmuch  as  they  show  that  the  primary  con- 
striction produced  in  making  and  maintaining  the  volvulus  which 
was  sufiicient  to  cause  venous  engorgement  in  the  twisted  loop, 
must  have  been  only  of  short  duration,  the  disappearance  of  the 
constriction  being  undoubtedly  due  to  the  gradual  yielding  of  the 
sutured  parts ;  while  the  faulty  axis  of  the  twisted  loop  was  main- 
tained by  the  sutures,  the  circulation  improved  and  remained  in  a 
sufficiently  vigorous  condition  to  adequately  nourish  the  most  distant 
portions  of  the  volvulus.  In  most  cases  where  I  made  a  volvulus 
artificially,  the  animals  did  not  sufPer  from  intestinal  obstruction, 
and  yet  the  examination  of  the  specimens  showed  that  the  twist  had 
remained.  The  shortness  of  the  mesentery  had  undoubtedly  a 
great  deal  to  do  with  the  restoration  of  the  circulation  in  the  twisted 
loop,  as  this  portion  of  the  bowel  immediately  after  fixation  always 
presented  a  cyanosed  appearance.  While  it  was  found  difiicult  to 
force  fluid  through  a  specimen  of  volvulus,  during  life,  propul- 
sion of  the  intestinal  contents  by  peristaltic  action  was  carried  on  in 
a  satisfactory  manner,  as  the  bowel  above  the  volvulus  was  not 
dilated,  and  contained  no  abnormal  amount  of  fluid,  and  the  animals 
manifested  no  symptoms  indicative  of  intestinal  obstruction.  In 
eases  where  death  has  been  produced  by  volvulus  the  post-mortem 
appearances  will  show  that  the  obstruction  was  caused  not  so  much 
from  mechanical  causes  as  from  the  secondary  pathological  condi- 
tions in  the  twisted  loop.  The  abnormal  length  of  the  mesentery 
found  in  these  cases  precludes  the  possibility  of  partial  or  complete 
spontaneous  reposition,  and  the  consequence  is  that  the  parts  in- 
volved in  the  volvulus  become  the  seat  of  serious  vascular  disturb- 
ances which  lead  to  oedema  and  paresis.  These  secondary  conditions 
are  followed  by  distention  of   the  intestine  and  accumulation   of 


100  INTESTINAL  SURGERY. 

intestinal  contents,  which  cannot  fail  in  aggravating  the  mechanical 
difficulties  which  initiated  the  obstruction. 

A  number  of  these  points  are  well  illustrated  by  a  case  of  volvu- 
lus reported  by  Wilson.^  A  boy,  nineteen  years  of  age,  without  any 
premonitory  symjDtoms,  was  suddenly  seized  with  symptoms  of  acute 
intestinal  obstruction.  Colicky  pains  and  persistent  vomiting  were  the 
most  conspicuous  symptoms.  Tenderness  over  the  umbilicus  and 
slight  fullness  between  pubic  arch  and  umbilicus.  Whole  abdomen 
tympanitic.  Pulse  rapid  and  small.  Skin  pale  and  cold.  The  patient 
died  thirty -two  hours  after  the  commencement  of  the  attack.  The 
necropsy  showed  moderate  distention  of  the  intestines,  which  were 
also  found  congested.  Four  or  five  loops  of  the  small  intestines 
occupying  the  hypogastrium  were  of  a  deep  purplish -black  color, 
and  gangrenous.  They  were  also  considerably  more  distended  than 
the  surrounding  gut,  and  taken  together,  they  compared  exactly  with 
the  outline  of  the  circumscribed  tympanitic  distention  observed 
during  life  in  this  region  of  the  abdomen.  On  careful  examination, 
these  blackened  coils  of  intestine  were  found  to  constitute  a  portion 
of  the  ileum,  five  feet  in  length,  tightly  twisted  upon  itself  in  its 
mesenteric  axis.  The  lower  point  of  crossing  was  five  inches 
above  the  ileo-csecal  valve.  At  the  point  of  crossing  of  the  upper 
and  lower  end  of  the  volvulus  the  intestines  were  flattened,  and  with 
the  corresponding  mesentery  tightly  twisted  upon  itself,  formed  a 
firm,  hard,  cord-like  pedicle  about  an  inch  and  a  half  in  length,  and 
a  little  more  than  one-third  of  an  inch  in  diameter.  The  twist  was 
from  left  to  right,  and  amounted  to  a  complete  turn  upon  the 
vertebro- enteric  axis  of  the  mesentery.  The  gangrene  and  rapidly 
fatal  termination  in  this  case  were  due  to  the  compression  of  veins  at 
the  base  of  the  volvulus  and  not  to  the  obstruction.  In  reference  to 
the  causation  of  volvulus  a  number  of  theories  have  been  advanced. 
All  authors  are  agreed  upon  one  point,  that  the  mesentery  must  be 
of  abnormal  length. 

Grawitz^  asserts  that  the  immediate  cause  of  a  volvulus  is  to 
be  found  in  an  accumulation  of  intestinal  contents  above  a  con- 
stricted portion  of  bowel;  that  the  distended  portion  of  intestine 
above  the  seat  of  constriction  undergoes  elongation,  and  that  this 

^  Amer.  Journal  of  Med.  Sciences,  July,  1878,  p.  78. 
2  Virchow  u.  Hirsch's  Jahresbericht,  B.  1,  1876,  p.  284. 


VOLVULUS.  101 

elongated  portion  then  rotates  around  its  axis.  Henning  ^  studied  the 
aetiology  of  volvulus  experimentally.  He  firmly  ligated  the  intes- 
tine in  animals  and  then  injected  water  above  the  seat  of  obstruc- 
tion. In  the  small  intestines  the  distended  and  elongated  coils 
above  the  ligature  always  showed  a  tendency  to  rotate  upon  their 
vertebro-mesenteric  axis,  and  thus  a  volvulus  was  produced.  In 
the  large  intestines,  on  account  of  the  shortness  of  the  mesenteric 
attachment,  the  ,same  experiment  caused  rupture  of  the  bowel  before 
a  volvulus  could  be  produced.  He  collected  a  number  of  cases  of 
volvulus  scattered  through  the  literature,  where,  in  the  post-mortem 
description  of  the  twisted  bowel,  it  was  distinctly  stated  that  the 
lumen  of  the  intestine  was  narrowed  by  some  form  of  acquired  or  con- 
genital stenosis.  While  it  cannot  be  denied  that  chronic  obstruction 
may  be  a  direct  or  indirect  cause  of  volvulus  by  producing  not  only 
elongation  of  the  intestine,  but  also  of  the  mesentery  above  the  seat 
of  obstruction,  many  cases  have  been  reported  where  no  such  con- 
dition was  found,  and  where,  therefore,  the  lesion  was  due  to  other 
causes. 

Nieberding^  has  recently  called  attention  to  another  cause  of 
volvulus.  He  has  reported  a  case  which  occurred  in  Bumm's 
practice,  where,  after  an  ovariotomy,  a  volvulus  of  the  small  intes- 
tine occurred  which  proved  fatal  after  a  few  days.  During  the 
operation,  the  omentum,  which  was  adherent  to  the  cyst,  was  sepa- 
rated and  a  portion  was  excised.  The  necropsy  showed  that  the  raw 
surface  of  the  omental  stump  had  formed  an  adhesion  to  a  loop  of 
the  small  intestine,  and  above  the  fixed  point  a  volvulus  was  found. 
He  reported  another  and  somewhat  similar  case  which  came  under 
his  own  observation.  A  large  cysto-sarcoma  of  the  left  ovary  was 
removed,  in  a  girl  twenty-nine  years  of  age.  Before  closing  the 
wound  it  was  noticed  that  the  omentum  was  so  short  that  the  intes- 
tines could  not  be  covered  by  it  in  the  region  of  the  incision.  At 
the  end  of  the  second  day  symptoms  of  acute  obstruction  set  in,  the 
temperature  remaining  normal.  As  the  symptoms  increased  in 
gravity,  and  the  ordinary  treatment  proved  fruitless,  the  wound  was 
opened  and  a  loop  of  intestine  was  found  adherent  to  the  left  margin 

^  Beitrage  zur  Kenntniss  der  Pathogenese  des  Volvnlns.  Dissertation. 
Berlin,  1883. 

^  Beitrage  zur  Darmocclusion  nach  ovariotomie.  Centralblatt  f .  GynSkol- 
ogie,  No.  12,  1888. 


102  INTESTINAL  SURGERY. 

of  the  peritoneal  wound,  and  after  this  was  separated  a  volvulus  was 
detected.  The  bowel  was  untwisted  and  its  contents  forced  into 
the  segment  further  down,  beyond  the  seat  of  obstruction,  the 
detached  loop  pushed  beyond  the  reach  of  the  abdominal  wound, 
and  the  abdomen  closed.  .The  day  after  the  operation  the  intestinal 
canal  appeared  to  be  permeable,  as  gas  escaped  per  rectum,  but 
evidences  of  peritonitis  set  in  and  the  patient  died  with  symptoms 
of  collapse.  He  believes  that  the  peritonitis  was  produced  by  the 
obstruction. 

G.  Braun^  reports  a  case  of  volvulus  in  a  woman  occurring 
at  the  end  of  pregnancy,  and  believes  that  the  pressure  of  the  gravid 
uterus  upon  the  sigmoid  flexure  produced  the  obstinate  constipation 
which  preceded  the  attack,  and  gave  rise  to  elongation  of  the  mesen- 
tery and  bowel  above  the  seat  of  compression,  to  a  sufficient  extent 
to  cause  volvulus.  At  the  time  she  was  admitted  to  the  hospital 
the  abdomen  was  enormously  distended,  nausea  but  no  vomiting.  On 
the  next  day  labor  pains  set  in  and  she  was  delivered  of  a  dead 
child.  On  the  same  day  vomiting  commenced  and  a  tendency  to 
collapse  was  observed.  The  day  after  delivery  she  complained  of 
intense  pain  in  the  abdomen,  difficulty  in  breathing,  and  great  pros- 
tration, and  in  a  few  days  she  died,  the  symptoms  pointing  to  an 
intestinal  obstruction  remaining  constant.  At  the  necropsy  the  sig- 
moid flexure  and  its  mesentery  were  found  greatly  elongated  and 
rotated  twice  around  its  axis.  That  volvulus  is  not  a  frequent  com- 
plication of  pregnancy  becomes  apparent  from  the  statement  of 
Braun,  that  this  was  the  first  case  in  sixty  thousand  deliveries  which 
had  come  under  his  own  observation. 

Kuettner^  had  unusual  opportunities  to  study  this  form  of 
intestinal  obstruction,  as  four  cases  came  under  his  own  treatment  in 
the  short  space  of  two  and  a  half  years.  As  predisposing  causes  he 
mentions  advanced  age  and  emaciation,  as  the  latter  is  attended  by  an 
absence  of  fat  in  the  omentum  and  mesentery,  which  renders  the 
peritioneal  cavity  more  spacious.  Abnormal  length  of  mesentery  and 
intestinal  tract  is  also  enmnerated  as  an  important  element  in  the 
causation  of  volvulus.     Among  the  exciting  causes  he  mentions  as 

'  Enterostenosen  in  ihrer  Beziehung  zur  Graviditat  und  Geburt.      Wiener 
Med.  Wochenschrift,  No.  24,  1885. 

2  Ueber  innere  Incarcerationen.     Virchow's  Archiv.,  B.  43,  p.  478. 


VOLVULUS.  103 

the  most  important,  unequal  distribution  of  intestinal  contents  and 
exaggerated  peristalsis.  He  never  observed  peritonitis  in  any  of  his 
cases,  even  if  life  was  prolonged  for  five  to  six  days.  He  believes 
that  in  these  cases  the  rapid  fatal  termination  is  due  to  pressure  upon 
the  sympathetic  nerves,  which  causes  paralysis  and  destroys  life  in 
the  same  manner  as  in  peritonitis.  He  asserts  that  the  complicated 
forms  of  knotting  of  the  intestine  which  are  still  described  in  the 
text-books  as  rare  but  distinct  forms  of  obstruction,  are  only  varieties 
of  volvulus. 

Treatment. 

Treves  in  his  paper  on  "  The  Operative  Treatment  of  Intestinal 
Obstruction*'^  claims  that  this  form  of  obstruction  is  only  aggra- 
vated by  forcible  rectal  injections,  as  such  a  procedure  will  tend 
to  tighten  rather  than  to  relax  the  twist.  Of  the  operative 
treatment  he  says  that  simple  laparotomy  is  an  unpromising  pro- 
cedure, but  that  in  the  future  he  will  make  the  incision  in  the 
median  line,  prmcture  the  gut,  and  attempt  its  reduction;  if  this 
fail,  or  the  result  appear  unsatisfactory,  he  will  evacuate  the  involved 
gut  through  an  opening  in  the  summit  of  the  flexure,  unfold  the 
volvulus,  and  establish  an  artificial  anus,  using  the  opening  just 
mentioned  for  that  purpose.  In  some  cases  of  vohoilus  the  rotation 
around  the  vertebro -mesenteric  axis  is  often  less  than  one  complete 
circle,  and  before  the  involved  bowel  has  become  considerably 
changed  by  the  twist,  a  reduction  might  be  effected  by  dilating  and 
elongating  the  bowel  below  the  seat  of  obstruction,  thus  bringing  the 
same  causes  to  bear  which  have  produced  the  displacement,  but  in 
an  opposite  direction.  Careful  inflation  with  hydrogen  gas  soon 
after  the  obstruction  has  occurred  will  be  a  harmless  procedure,  and 
in  favorable  cases  might  lead  to  the  desired  result.  Why  this 
method  of  reduction  should  not  be  tried  after  the  twisted  loop  has 
become  softened  and  greatly  distended  by  intestinal  contents,  requires 
no  explanation. 

Of  all  forms  of  intestinal  obstruction  volvulus  leads  most  rapidly 
to  a  fatal  termination.  This  fact  alone  is  a  sufiicient  warning  to  lose 
but  little  time  by  temporizing  measures.  If  life  is  to  be  saved 
prompt  operative  treatment  must  be  adopted.  After  the  symptoms 
have  become  sufficiently  well  marked,  if  insufflation  proves  rmavail- 

1  The  British  Medical  Journal,  August  29,  1885. 


104-  INTESTINAL  SURGERY. 

ing,  laparotomy  should  be  resorted  to  at  once  without  reference  to 
the  time  which  has  elapsed.  If  the  abdomen  is  opened  before  the 
bowel  has  undergone  serious  pathological  changes  reduction  will  not 
be  difficult,  and  as  the  intestine  is  otherwise  in  a  healthy  condition 
the  prospects  of  a  favorable  termination  are  good.  In  such  a  favor- 
able case  it  would  not  only  be  prudent,  but  imperative  to  resort  to 
means  to  prevent  a  recurrence  of  the  volvulus.  As  an  elongated 
mesentery  plays  the  most  important  role  in  its  production  the  best 
prophylactic  means  against  a  recurrence  would  be  to  shorten  the 
mesentery.  Resection  of  the  mesentery  is  out  of  question,  as  such 
a  procedure  might  result  in  gangrene  of  a  corresponding  portion  of 
the  gut.  Shortening  of  the  mesentery,  however,  can  be  effected  by 
folding  and  suturing  the  mesentery  in  the  same  manner  as  has  been 
described  in  treating  of  the  operative  treatment  of  invagination. 
Such  an  expedient  would  shorten  the  mesenteric  attachment  without 
interfering  with  the  intestinal  circulation.  If  the  twisted  po-rtion  of 
the  intestine  presents  evidences  of  gangrene,  resection  becomes  neces- 
sary, and  after  it  has  been  done  the  continuity  of  the  intestinal  canal 
should  be  restored  by  circular  enterorrhaphy  or  by  lateral  approxi- 
mation with  decalcified  perforated  bone  plates.  If  reduction  cannot 
be  accomplished  without  evacuating  the  distended  bowel,  an  incision 
should  be  made  on  its  convex  surface  at  the  summit  of  the  loop,  and 
its  contents  removed  by  pouring  out,  taking,  of  course,  all  the  neces- 
sary precautions  not  to  soil  the  peritoneal  cavity.  After  this  has  been 
done  the  visceral  wound  should  be  sutured  and  another  attempt 
made  at  reduction.  If  this  does  not  succeed  and  the  symptoms  are 
such  that  the  necessary  time  required  for  resection  would  prove  an 
element  of  danger,  the  volvulus  should  be  left  and  the  obstruction 
rendered  harmless  by  establishing  a  communication  between  the 
bowel  above  and  below  the  volvulus,  by  lateral  apposition  with  decal- 
cified perforated  bone  plates. 

4.     Obstruction   by,  Flexions  and  Adhesions. 

Every  pathologist  who  has  carefully  examined  the  intestinal 
canal  of  persons  who  have  acute  peritonitis,  must  have  noticed  the 
presence  of  numerous  flexions  caused  by  visceral  and  parietal  adhe- 
sions, and  yet  such  patients  seldom  exhibited  well-marked  symptoms 
of  intestinal  obstruction  during  life.  I  have  observed  the  same  con- 
ditions in  animals  during  my  experimental  work  on  the  intestinal 


OBSTRUCTION  BY  FLEXIONS  AND  ADHESIONS.  105 

canal  and  seldom  found  that  simple  flexion  gave  rise  to  intestinal 
obstruction.  I  have  made  numerous  flexions  when  performing 
operations  for  establishing  intestinal  anastomosis,  and  in  most 
instances  satisfied  myself  by  examination  of  the  specimens  that  fluids 
passed  them  without  great  difficulty.  If  the  bowel  at  the  point  of 
flexion  remains  free,  certain  portions  of  its  walls  will  yield  to  pressure 
from  within  of  the  fluid  intestinal  contents,  and  gradually  the  lumen 
of  the  bowel  will  become  restored.  If,  on  the  other  hand,  the  entire 
circumference  of  the  bowel  at  the  point  of  flexion  has  become  fixed 
and  immovable  by  inflammatory  adhesions  or  other  pathological 
products,  a  compensating  dilatation  becomes  impossible  and  flexion 
becomes  a  direct  and  serious  cause  of  obstruction.  In  recent  cases 
of  flexion,  of  course  the  circumference  of  the  lumen  of  the  bowel  at 
the  point  of  flexion  is  equal  in  size  to  that  above  or  below  the 
obstruction.  The  obstruction  in  such  cases  is  not  caused  by  stenosis, 
but  by  compression  of  the  distal  limb  of  the  flexion  by  the  intestinal 
contents  in  the  proximal  portion,  thus  causing  a  valvular  closure  not 
at,  but  just  beyond  the  seat  of  flexion.  This  is  more  likely  to  take 
place  if  the  apex  of  the  flexed  portion  of  the  bowel  is  adherent  to 
some  fixed  point,  as  in  this  case  a  compensatory  dilatation  of  the  intes- 
tinal wall  at  a  point  corresponding  to  the  apex  of  the  flexion,  cannot 
take  place.  When  a  flexion  has  existed  for  a  long  time  without 
having  given  rise  to  symptoms  of  obstruction,  it  finally  may  cause 
occlusion  by  a  cicatricial  stenosis  at  the  seat  of  flexion,  due  to  a 
circumscribed  plastic  inflammation  and  cicatricial  contraction  of  the 
inflammatory  product. 

Such  a  case  came  under  the  observation  of  Obalinski.^  A  boy, 
eighteen  years  old,  had  suffered  from  typhoid  fever  eight  months 
before  the  attack  of  intestinal  obstruction  set  in.  Some  time  before 
the  acute  symptoms  appeared  he  suffered  from  pain  in  the  abdomen 
which  gradually  increased  in  intensity  until  the  clinical  picture  of , 
obstruction  was  well  marked.  On  the  eighth  day  after  the  attack, 
the  abdomen  was  opened  by  a  median  incision.  Distended  and  col- 
lapsed intestinal  coils  came  within  easy  reach.  The  obstruction 
consisted  of  a  rectangular  flexion  of  the  small  intestine  caused  by  a 
pseudo-ligament  the  size  of  a  lead  pencil.     After  division  of  this  band 

1  Weitere  Beitrage  zur  Laparotomie  bei  inneren  Darmocclusionen.  Wiener 
Med.  Presse,  Nos.  4-12,  1886. 


106  INTESTINAL  SURGERY. 

and  straightening  the  bowel,  it  was  seen  that  it  was  considerably 
contracted  at  the  -point  of  flexion  by  a  circular  cicatrix,  but  as  it  was 
permeable  nothing  further  was  done.  The  boy  was  discharged  cured 
four  weeks  after  the  operation.  That  the  pressure  of  intestinal  con- 
tents in  the  proximal  bar  is  exerted  mainly  upon  the  spur  which 
forms  in  acute  flexions  between  the  two  bars,  is  well  shown  by  a 
specimen  described  by  Birkett,'  where  an  intestinal  anastomosis  was 
established  spontaneously  by  ulceration  between  the  approximated 
adherent  tubes  at  the  point  of  compression,  so  that  the  intestinal  con- 
tents passed  directly  from  one  intestine  to  the  other  through  this 
"fistula  bimucosa,"  instead  of  traversing  the  loop.  The  patient  was 
a  man,  aged  fifty-eight,  who  six  months  before  his  death  had  pre- 
sented a  strangulated  hernia  that  had  been  reduced  by  taxis. 

When  the  flexion  is  very  acute,  the  spur  formed  by  the  apex  of 
the  approximated  walls  of  both  bars  acts  like  a  valve  in  closing  the 
lumen  of  the  distal  bar,  under  the  influence  of  the  hydrostatic 
pressure  from  the  accumulation  of  intestinal  contents  above  the  seat 
of  flexion.  Nicaise"  has  reported  a  typical  case  of  this  kind.  A  man, 
aged  twenty-five  years,  was  operated  upon  for  strangulated  hernia 
five  years  before  the  attack  of  intestinal  obstruction.  Since  the 
herniotomy  he  had  suffered  frequently  from  attacks  of  vomiting  and 
constipation  with  abdominal  pain.  The  last  attack  was  so  severe 
that  enterotomy  was  performed.  He  died  the  next  day.  The 
necropsy  revealed  an  acute  flexion  which  had  become  permanent  by 
old  adhesions.  The  flexion  was  so  acute  that  the  mucous  membrane 
at  its  apex  constituted  a  kind  of  valve  across  the  lumen  of  the  bowel. 
After  liberation  of  a  flexed  bowel  the  seat  of  an  intestinal  obstruc- 
tion, it  becomes  a  step  in  the  operation  to  resort  to  such  prophylactic 
measures  as  may  appear  necessary  to  prevent  a  return  of  the  mal- 
position, and  to  cover  as  far  as  possible  the  peritoneal  defects  which 
have  been  made  during  the  separation  of  the  loop.  Winslow^  reports 
a  case  in  point.  In  this  case  a  loop  of  the  small  intestines  was  found 
firmly  adherent  in  the  pelvis  over  an  area  of  six  inches  and  sharply 
flexed.  After  it  was  carefully  detached  it  was  found  denuded  of 
peritoneum  over  a  small  space.  The  continuity  of  the  peritoneal 
surface  was  restored  by  applying  a  number  of  sutures  transversely 

1  Pathological  Soc.  Transactions,  vol.  X,  1859. 

2  Bulletin  et  Mem.  de  la  Soc.  de  Chirurgie,  Paris,  1880,  p.  583. 

3  Amer.  Journal  Med.  Sciences,  vol.  41,  p.  411. 


ADHESIONS.  107 

to  the  long  axis  of  the  bowel.  It  is  distinctly  stated  that  this  portion 
of  the  bowel  was  deeply  congested,  hence  the  seat  of  the  textural 
changes  consequent  upon  the  obstruction.  In  most  cases  of  flexion 
which  have  been  described  in  connection  with  intestinal  obstruction, 
the  flexed  bowel  was  found  either  in  the  pelvis  near  the  internal 
inguinal  rings,  or  in  the  ileo-csecal  region,  localities  where  localized 
peritonitis  is  most  frequently  met  with. 

If,  after  the  reduction  of  a  strangulated  hernia,  the  replaced 
loop  of  intestine  is  or  becomes  the  seat  of  a  plastic  peritonitis,  it 
forms  an  attachment  to  the  abdominal  parietes  or  viscera  with  which 
it  comes  in  contact.  In  case  the  adhesion  thus  formed  remains  firm 
and  is  not  drawn  out  in  the  form  of  a  band,  a  flexion  may  form  by 
the  free  portion  of  the  bowel  changing  its  relative  position,  and  the 
two  bars  of  the  flexion  thus  formed,  when  in  close  contact  and 
the  seat  of  the  same  plastic  inflammation,  become  adherent  and  the 
flexion  becomes  permanent.  If  the  continuity  of  the  bowel  cannot 
be  restored  by  separation  of  the  adhesions  in  the  operative  treatment 
of  obstruction  caused  by  flexion,  and  the  tissues  at  the  seat  of  obstruc- 
tion present  no  evidences  of  gangrene,  an  anastomosis  between  the 
two  bars  of  the  flexion  should  be  made  in  preference  to  resection  and 
circular  suturing.  Circumscribed  spots  of  gangrene  can  be  excised 
and  the  wound  sutured  transversely  to  the  long  axis  of  the  bowel, 
as  this  will  cause  no  stenosis  and  will  tend  to  correct  the  faulty  posi- 
tion of  the  bowel.  As  in  cases  of  constriction  by  bands,  if  it  is  found 
difl&cult  to  separate  the  adhesions,  no  attempt  should  be  made  to 
liberate  the  gut  until  a  rubber  ligature  has  been  applied  to  each 
bar  of  the  flexion,  to  prevent  fsecal  extravasation  should  the  bowel 
be  ruptured  during  the  separation. 

Adhesions. 

Quite  recently  a  number  of  abdominal  surgeons  have  published 
their  experience  in  reference  to  the  occurrence  of  intestinal  obstruc- 
tion after  laparotomy.  A  number  of  cases  of  intestinal  obstruction 
which  occurred  soon  after  ovariotomy  were  found  to  have  been  caused 
by  extensive  parietal  adhesions  of  the  intestines ;  hence  the  question 
has  been  discussed  how  such  adhesions  are  to  be  prevented. 

P.  Mueller  ^  has  advised  that  in  difiicult  ovariotomies  adhesions 

1  Zur  Nachbehandlung  schwerer  Laparotomien.     Archiv.  f.  Gynakologie, 
B.  28,  Heft  3. 


108  INTESTINAL  SURGERY. 

of  the  intestines  amongst  themselves,  and  with  the  abdominal  walls 
should  be  prevented  by  avoiding  external  compression  by  bandages, 
and  by  filling  the  abdominal  cavity  with  a  physiological  solution  of 
common  salt  (0.7  per  cent.)  For  the  purpose  of  limiting  peritoneal 
absorption,  he  suggests  that  the  solution  should  be  introduced  from 
time  to  time  and  finally  should  be  withdrawn  through  the  drainage 
tube. 

Olshausen'  has  found  in  all  the  cases  of  intestinal  obstruction 
after  ovariotomy  that  occurred  in  his  practice,  that  the  obstruction 
was  caused  by  adhesion  of  an  intestinal  loop  to  the  surface  of 
the  stump.  Mueller's  prophylactic  treatment  he  considers  rational, 
especially  in  cases  where  the  operation  is  attended  by  consider- 
able haemorrhage.  Schatz  holds  that  visceral  and  parietal  adhe- 
sions of  the  intestines  after  ovariotomy  are  a  much  more  frequent 
condition  than  is  generally  believed.  He  is  of  the  opinion  that 
serious  consequences  do  not  necessarily  follow  such  a  condition. 
Gusserow  asserts  that  adhesions  are  frequently  found  on  making  a 
second  laparotomy  in  the  same  patient,  which  had  not  produced  any 
untoward  symptoms. 

Kaltenbach  now  uses  a  1-6000  solution  of  sublimate  in  place  of 
carbolic  acid  solution,  and  since  he  has  made  this  changre  he  has  not 
observed  a  case  of  intestinal  obstruction  in  fifty-four  consecutive 
laparotomies,  while  of  twenty-four  cases  where  carbolic  acid  was 
used  he  lost  two  cases  from  this  cause.  Kruckenberg  attributes  to 
the  use  of  sublimate  an  influence  in  causing  plastic  adhesions  and 
asserts  that  since  he  has  abandoned  this  agent  he  has  had  no  cases 
of  internal  obstruction  after  ovariotomy.  Sanger's  experiments 
appear  to  prove  that  for  the  formation  of  a  firm  and  permanent  adhe- 
sion only  one  wounded  surface  is  necessary.  Schwarz  believes  that 
parietal  adhesions  along  the  internal  surface  of  the  abdominal 
wound  are  of  frequent  occurrence,  because  intestinal  loops  are  caught 
in  the  furrow  of  peritoneum  along  the  line  of  suturing,  where  addi- 
tional irritation  is  caused  by  the  sutures. 

Martin"  as  early  as  1865  reported  two  cases  which  illustrate  one 
of  the  dangers  which  follow  puerperal  pelvic  peritonitis.  In  one 
case  the  peritonitis  followed  a  manual  separation  of  the  placenta. 

'  Verb,  der  Deutschen  Gesellschaf t  ftir  Gynakologie,  1886. 
2  Zwei  Falle  von  Darmeinklemmung  durch  Exsudatfaden  nach  Wochen- 
betten.     Monatsschrift  fur  Geburtskunde,  July,  1865. 


ADHESIONS.  109 

The  patient  made  a  rapid  recoveiy,  but  six  weeks  later  symptoms  of 
acute  intestinal  obstruction  developed,  from  which  the  patient  died 
on  the  fourth  day.  On  post-mortem  the  cause  of  obstruction  was 
found  to  be  a  firm  pseudo-membranous  band  which  connected  the 
anterior  surface  of  the  caecum  with  a  coil  of  the  small  intestine.  In 
the  second  case  a  metro-peritonitis  followed  a  normal  delivery,  which, 
however,  yielded  to  proper  treatment  on  the  fifth  day.  During  the 
seventh  week  after  delivery  symptoms  of  acute  intestinal  obstruction 
set  in  and  the  disease  proved  fatal  after  a  few  days.  A  condition 
similar  to  that  in  the  first  case  was  foimd  at  the  post-mortem. 

Hirsch'  presents  at  length  the  results  of  his  observations  and 
researches  on  intestinal  obstruction  after  ovariotomy.  He  attributes 
intestinal  obstruction  after  ovariotomy  to  one  of  three  causes: 
1.  Adhesions  of  an  intestinal  loop  to  abdominal  incision,  and  occlu- 
sion from  the  traction  of  the  cicatrix.  2.  Aseptic  plastic  peri- 
tonitis, which  by  causing  extensive  adhesions  results  in  immobiliza-* 
tion  of  a  considerable  portion  of  the  intestinal  canal,  which  leads  to 
coprostasis  and  complete  obstruction.  3.  Impaction  of  an  intestinal 
loop  between  a  pedicle,  treated  by  the  extra-peritoneal  method,  and 
the  abdominal  wall.  Sir  Spencer  Wells  reported  eleven  deaths  from 
this  cause  in  one  thousand  eases  of  ovariotomy.  Usually  the 
obstruction  occurs  soon  after  the  operation,  but  several  years  may 
elapse  before  the  accident  takes  place.  The  symptoms  are  the  same 
as  in  obstruction  from  other  causes. 

The  prognosis  in  cases  of  obstruction  from  intestinal  adhesions 
is  extremely  unfavorable.  Of  the  fourteen  cases  collected  by  the 
writer,  only  one  recovered  after  secondary  laparotomy.  In  view  of 
the  great  mortality  which  attends  this,  the  most  serious  complication 
after  laparotomy,  it  is  exceedingly  important  to  resort  to  proper 
prophylactic  measures  in  all  cases  of  intra-abdominal  operations.  In 
the  first  place,  when  the  operation  is  done  in  an  aseptic  peritoneal 
cavity,  all  irritating  antiseptic  solutions  should  be  kept  from  coming 
in  contact  with  the  peritoneum,  as  their  local  irritant  action  might 
produce  a  plastic  peritonitis.  The  peritoneum  should  not  be  unnec- 
essarily bruised  or  sponged,  as  a  slight  traumatic  irritation  might 
be  productive  of  a  circumscribed  adhesive  inflammation.  Finally,  it 
should   be   the   aim   of   the   surgeon   to   restore,    if    possible,    the 


1  Archiv.  f.  Gynakologie,  B.  XXXII,  Heft  2. 


•       110  INTESTINAL  SURGERY. 

continuity  of  the  peritoneal  surface,  should  any  defects  be  found 
during,  or  caused  by  the  operation,  before  ihe  abdomen  is  closed. 
Adhesion  of  the  intestines  to  the  abdominal  incision  can  be  prevented 
by  spreading  the  omentum  carefully  over  the  intestines  the  whole 
length  of  the  incision.  Limited  defects  can  be  readily  closed  by 
j  suturing.     The  cut  surface  of  the  pedicle  after  ovariotomy  should  be 

^  covered  by  stitching  the  peritoneum  over  it.  ■   The  stump,  after  supra- 

vaginal amputation,  is  treated  in  a  similar  manner.  Parietal  and 
visceral  defects  not  amenable  to  suturing  can  be  covered  with  an 
omental  graft,  which  is  stitched  to  the  margins  of  the  defect  with 
catgut  sutures.  In  cases  of  intestinal  obstruction  due  to  extensive 
adhesions  after  operations,  or  attacks  of  circumscribed  peritonitis,  it 
is  essential  to  resort  to  early  operative  treatment,  which  consists  in 
separating  the  adhesions  and  in  restoring  peritoneal  defects  as  far  as 
possible,  for  the  purpose  of  guarding  against  similar  attacks  in  the 
future.  After  the  intestine  has  been  liberated,  it  is  advisable  to  place 
the  detached  portion  in  some  part  of  the  abdominal  cavity  where  a 
similar  condition  is  less  likely  to  occur. 

5.     Strangulation  by  Ligamentous  Bands  or  Diverticula. 

Ligamentous  bands  resulting  from  old  adhesions  are  usually 
found  in  parts  of  the  abdominal  cavity  most  frequently  the  seat  of 
peritonitis,  viz.:  in  the  pelvis  and  the  ileo-csecal  region.  Their 
formation  can  generally  be  traced  to  a  broad  parietal  adhesion, 
which  by  the  peristaltic  action  of  the  free  portion  of  the  intestine, 
has  become  elongated  and  often  narrowed  to  a  delicate  cord.  It 
becomes  a  cause  of  obstruction  when  the  migrating  or  free  end  forms 
an  attachment  to  some  fixed  point,  which  then  renders  the  band  tense 
and  unyielding.  In  case  a  loop  of  intestine  becomes  ensnared 
underneath  it  strangulation  takes  place  in  the  same  manner  as  in 
strangulated  hernia,  the  constricting  cord  by  its  pressure  causing 
venous  engorgement  below  the  constriction,  and  by  the  increased 
peristaltic  action  of  the  proximal  limb  of  the  loop  forcing  intestinal 
contents  into,  but  not  through,  the  constricted  loop.  As  in  hernia, 
an  intestine  may  have  become  adherent  and  fixed  underneath  such  a 
band  for  an  indefinite  period  of  time  witho.ut  strangulation  taking 
place,  as  long  as  the  immediate  causes  of  strangulation  are  absent. 
Any  causes  which  disturb  the  mechanical  relations  still  further  in 
such  a  case,  as  a  fall,  lifting,  coughing,  the  administration  of  an  active 


LIGAMENTOUS  BANDS   OR   DIVERTICULA.  HI 

cathartic,  etc.,  may  bring  on  an  acute  attack  of  intestinal  obstruction. 
The  history  of  cases  of  obstruction  due  to  the  presence  of  a 
ligamentous  band  frequently  refers  to  an  attack  of  peritonitis 
through  which  the  patient  passed  perhaps  years  before,  and  as 
frequently  alludes  to  one  of  the  above-mentioned  proximate  causes 
as  preceding  the  attack  of  intestinal  obstruction. 

A  displaced  neck  of  hernial  sac  may  cause  obstruction  in  the 
same  manner  as  a  ligamentous  band.  Kurz'  treated  such  a  case 
successfully  by  laparotomy.  The  patient,  a  man  thirty-three  years 
of  age,  had  been  the  subject  of  a  small  inguinal  hernia  for  several 
years  without  causing  much  inconvenience.  When  symptoms  of 
acute  intestinal  obstruction  set  in,  the  inguinal  canal  was  carefully 
examined  and  was  found  empty.  The  symptoms  of  obstruction 
were  very  grave,  including  a  subnormal  temperature  and  faecal 
vomiting  at  the  time  the  operation  was  performed.  Digital  explora- 
tion of  the  ileo-csecal  region  through  a  median  abdominal  incision, 
led  to  the  discovery  of  a  ring  in  which  the  colon  had  become 
ensnared.  Reduction  by  moderate  traction  was  found  impossible, 
and  it  was  found  necessary  to  incise  the  ring  at  two  points,  when 
the  bowel,  which  was  deeply  congested,  was  readily  withdrawn. 
The  ring  was  found  displaced  four  inches  from  the  internal  ring. 
The  patient  made  a  rapid  and  satisfactory  recovery.  In  other 
instances  the  contents  of  a  hernia,  either  the  omentum  or  the  intes- 
tinal loop,  when  in  a  condition  of  plastic  inflammation,  may  lead  to 
the  formation  of  a  ligamentous  band  when  either  of  these  structures 
becomes  attached  near  to  the  internal  ring,  the  adhesion  which 
forms  lengthening  out  until  it  is  attached  to  some  other  fixed  point. 
Obre"  described  the  post-mortem  appearances  of  such  a  case.  The 
strangulated  loop  had  wandered  nearly  to  the  xiphoid  cartilage; 
while  between  it  and  the  inguinal  ring  a  cord  seventeen  inches  long 
was  found. 

A  band  of  constriction  can  also  be  formed  by  the  margins  of 
an  opening  in  the  mesentery  or  omentum  in  which  a  loop  of  intes- 
tine can  become  strangulated.  In  such  cases  it  becomes  necessary 
after  reduction  has  been  efPected,  to  close  the  opening  by  sutures  to 
prevent  a  possible  relapse  of  the  obstruction  from  the  same  cause. 

'  Deutsche  Med.     Wochenschrift,  March  26,  1885. 
2  Pathological  Society  Transactions,  1851,  p.  95. 


112  INTESTINAL  SURGERY. 

An  adherent  portion  of  omentum  in  the  course  of  time  may  become 
drawn  out  into  a  narrow  twisted  cord  which  may  become  a  cause 
of  interna]  strangulation.  In  operating  for  intestinal  obstruction 
caused  by  constricting  bands,  it  is  always  necessary,  after  relieving 
the  point  of  constriction  first  found,  to  search  for  additional  bands, 
as  it  is  not  unusual  to  find  more  than  one.  Obalinski^  made  a 
laparotomy  for  intestinal  obstruction  on  the  third  day  after  the 
appearance  of  acute  symptoms.  On  introducing  his  hand  through 
a  median  incision  he  felt  in  the  right  iliac  region  distended  and 
empty  coils,  and  by  tracing  the  latter  in  an  upward  direction  found 
as  the  cause  of  obstruction  two  bands,  each  the  size  of  a  goose-quill, 
extending  from  the  caecum  to  the  abdominal  wall,  between  which  a 
loop  of  intestine  30  cm.  in  length  had  become  strangulated.  Both 
bands  were  ligated  and  divided.  Bowels  moved  on  the  fourth  day 
and  patient  was  discharged  cured  in  two  weeks.  Fowler^  has  met 
with  two  cases  where,  at  the  autopsy,  a  second  band  was  found  close 
to  the  divided  one. 

Another  frequent  location  for  bands  is  in  the  umbilical  region, 
where  the  remains  of  the  umbilical  artery  may  become  a  cause  of 
constriction.  Polaillon"*  opened  the  abdomen,  in  a  young  man,  by 
lateral  incision  on  right  side  for  intestinal  obstruction,  one  week 
after  the  appearance  of  the  first  symptoms.  As  the  patient  was  the 
subject  of  an  inguinal  hernia,  both  inguinal  canals  were  examined 
by  digital  exploration  through  this  incision,  but  nothing  was  found 
to  explain  the  obstruction.  The  incision  was  enlarged  and  the 
whole  hand  introduced,  and  after  careful  exploration  a  falciform 
fold  was  found  to  the  left  of  the  median  line,  which  extended  from 
the  left  inguinal  ring  toward  the  umbilicus.  Between  the  band  and 
the  abdominal  wall  a  sac  was  found  which  contained  numerous  coils 
of  intestine.  The  whole  intestine  was  carefully  examined,  and 
finally  an  empty  loop  about  ten  inches  in  length  was  found.  The 
cause  of  strangulation  was  the  peritoneal  band,  reduction  having 
taken  place  by  the  introduction  of  the  hand.  The  band  was  not 
divided  for  fear  of  hsemorrhage.  The  patient  recovered  after  a 
slight  attack  of  peritonitis. 

Intestinal   obstruction   by    a   constricting   band   furnishes  the 

1  Wiener  Med.  Prtsse,  No.  4-12,  1886. 

2  The  Lancet,  June  30,  1883,  p.  1120. 

^  Gazette  Medicals  de  Paris,  April  25,  1885. 


LIGAMENTOUS  BANDS   OR   DIVERTICULA.  113 

simplest  and  most  favorable  conditions  for  early  operative  treatment 
by  abdominal  section.  Without  prompt  surgical  treatment  a  fatal 
termination  is  almost  inevitable,  as  death  results  either  from  the 
mechanical  efPects  of  the  obstruction,  or  the  constriction  produces 
gangrene  of  the  entire  loop,  or  circumscribed  gangrene  under  the 
sharp  margin  of  the  band,  followed  by  perforation,  and  death  from 
septic  peritonitis.  An  operation  undertaken  before  the  strangula- 
tion has  caused  great  abdominal  distension  and  serioiis  textural 
changes  by  pressure  or  constriction  would  be  almost  sure  to  be 
rewarded  by  success.  Two  cases  of  intestinal  obstruction  caused  by 
ligamentous  bands,  recently  reported  by  Bull ',  illustrate  in  a  most 
striking  manner  the  importance  of  early  operative  interference. 
Both  cases  were  treated  by  laparotomy,  and  the  difference  in  the 
results  obtained  was  plainly  traceable  to  the  length  of  time  which 
had  intervened  between  the  onset  of  the  disease  and  the  operation. 
In  the  first  case  the  operation  was  delayed  until  the  eleventh  day, 
and  during  the  separation  of  the  band  a  gangrenous  spot  in  the 
bowel  gave  way,  followed  by  fsecal  extravasation.  The  circum- 
scribed gangrenous  patch  was  excised,  making  a  wound  an  inch  in 
length,  and  parallel  to  the  long  axis  of  the  bowel,  which  was  closed 
with  twelve  Lembert  sutures.  Death  twelve  hours  after  operation. 
In  the  second  case  laparotomy  was  performed  almost  under  identical 
circumstances,  but  the  strangulation  had  existed  only  six  days.  In 
this  case  the  operation  was  limited  to  the  removal  of  the  cause  of 
obstruction,  as  the  constricted  bowel  had  not  undergone  irreparable 
damage,  and  the  patient  recovered. 

The  operative  treatment  of  the  obstruction  in  this  form  of 
intestinal  strangulation  is  usually  not  attended  by  any  difficulties. 
The  band  of  constriction,  whatever  its  location  or  mode  of  origin 
may  be,  is  traced  to  both  the  fixed  points  of  attachment  and  excised 
between  two  ligatures.  This  not  only  relieves  the  strangulation, 
but  prevents  a  possible  recurrence  of  a  similar  attack  from  the  same 
cause.  In  some  instances,  however,  the  local  conditions  may  be 
more  complicated.  Reali  met  with  a  case  where  it  was  found  im- 
possible to  liberate  the  intestine  from  a  constricting  band,  and  where 
he  divided  the  intestine  at  the  point  of  constriction  and  united  the 
ends  again  by  circular  suturing,  and  his  patient  recovered.       If  on 

1  Report  of  Cases  of  Intestinal  Obstruction  treated  by  Laparotomy.    Gail- 
lard's  Medical  Journal,  March,  1888. 
8 


114  INTESTINAL  SURGERY. 

careful  examination  the  conditions  at  the  seat  of  constriction  are 
such  as  make  it  probable  that  the  gut  is  the  seat  of  gangrene  from 
compression  underneath  the  band,  or  that  the  separation  of  the  band 
from  the  intestine  is  not  readily  accomplished,  no  attempts  should  be 
made  to  liberate  the  intestine  until  measures  have  been  employed  to 
guard  against  fsecal  extravasation  in  case  the  gut  should  be  ruptured. 
This  precaution  consists  in  emptying  the  intestine  on  each  side  of 
the  constriction  to  a  distance  of  from  two  to  four  inches,  by  displac- 
ing the  contents  in  its  interior  betvreen  the  thumb  and  index  finger 
and  applying  a  rubber  ligature,  which  is  passed  through  the  mes- 
entery with  a  pair  of  haemostatic  forceps.  The  ligatures  are  not 
removed  until  the  bowel  has  been  liberated,  and  if  it  is  injured  or 
presents  evidences  of  gangrene,  not  until  its  continuity  has  been 
restored  by  suturing  or  excision,  or  by  establishing  an  anastomosis 
after  resection. 

From  a  surgical  standpoint  in  the  causation  and  treatment  of 
intestinal  obstruction,  the  appendix  vermiformis  must  be  looked 
upon  as  a  diverticulum.  The  appendix  vermiformis  may  become  a 
cause  of  obstruction  when  it  is  of  abnormal  length  and  supplied  by 
a  long  mesentery,  and  when  it  is  transformed  into  an  unyielding 
band  by  fixation  of  its  free  extremity  to  some  firm  point,  by  adhesive 
inflammation.  Greves '  reports  such  a  case.  A  boy,  six  years  of  age, 
who  had  suffered  frequently  from  attacks  of  constipation  lasting 
from  a  few  days  to  a  week  or  fortnight,  was  seized  with  a  violent 
pain  in  the  bladder  and  other  symptoms  of  acute  internal  strangula- 
tion. On  the  fourth  day  the  pain  was  referred  to  the  iliac  region, 
where  a  resonant  swelling  could  be  located.  As  the  usual  means 
proved  of  no  avail  laparotomy  was  performed  on  the  fifth  day. 
About  twelve  inches  of  the  small  intestines  were  found  to  be  tightly 
strangulated  by  an  abnormal  appendix  vermiformis,  whose  free  end 
had  become  fixed  to  the  iliac  fossa,  forming  a  complete  ring,  through 
which  the  small  intestine  had  slipped  and  become  strangulated. 
Strangulation  was  relieved  by  division  of  the  ring.  Patient  had  not 
a  single  bad  symptom  after  the  operation.  Excision  of  the  appendix 
vermiformis,  when  the  cause  of  obstruction,  should  always  be  prac- 
ticed with  a  view  of  preventing  a  similar  attack  from  the  same  cause. 
As  in  such  cases  the  process  has  undergone  elongation  by  traction, 

1  The  Lancet,  December  6,  1884. 


LIGAMENTOUS  BANDS    OR   DIVERTICULA.  115 

it  is  sufficient  to  apply  a  ligature  near  its  base  and  then  remove  it 
by  excision. 

Quite  a  number  of  cases  of  intestinal  obstruction  are  on  record 
where  the  obstruction  was  caused  by  a  diverticulum,  and  in  a  number 
of  these  cases  the  strangulation  was  successfully  treated  by  lapar- 
otomy. To  the  same  class  belong  bands,  the  remains  of  obliterated 
omphalo-mesenteric  vessels. 

In  1851  Parise^  published  his  paper  on  a  new  cause  of  strangu- 
lation, in  which  he  claimed  that  he  was  the  first  one  to  show  that 
strangulation  may  take  place  from  constriction  by  a  diverticulum. 
The  same  year  Bonvier"  described  a  case  where  a  diverticulum  of 
unusual  length,  springing  from  the  ileum  three  feet  above  the  ileo- 
caecal  valve,  encircled  a  loop  of  the  small  intestine  so  firmly  as  to 
give  rise  to  complete  obstruction.  Where  the  diverticulum  joined 
the  ileum  the  lumina  of  both  were  equal  in  diameter,  but  the 
diverticulum  tapered  towards  its  end,  ending  in  a  bifid  extremity, 
adherent  to  intestinal  coils.  Omentum  and  abdominal  wall  furnished 
the  unyielding  points.  The  constriction  was  not  very  firm  and 
reduction  could  have  been  readily  effected  had  an  abdominal  section 
been  made. 

Fitz,^  in  an  exhaustive  article  on  "  Persistent  Omphalo-mesen- 
teric Remains ",  has  collected  all  material  facts  pertaining  to 
Meckel's  diverticulum,  with  especial  reference  to  the  causation  of 
internal  strangulation.  As  the  result  of  a  careful  study  of  this  sub- 
ject he  has  come  to  the  following  conclusions : 

V    1.     Bands  and  cords  as  a  cause  of  acute  intestinal  obstruction 
are  second  in  importance  to  intussusception  alone. 

2.  Their  seat,  structure,  and  relation  are  such  as  frequently 
admit  their  origin  from  obliterated  or  patent  omphalo-mesenteric 
vessels,  either  alone  or  in  connection  with  Meckel's  diverticulum,  and 
oppose  their  origin  from  peritonitis. 

3.  Recorded  cases  of  intestinal  obstruction  from  Meckel's 
diverticulum,  in  most  instances  at  least,  belong  in  the  above  series. 

^  Memoire  sur  le  mecanisme  de  1'  etranglement  intestinal  par  un  noeud 
diverticulair.     Bull,  de  1'  Acad,  de  Med.,  1851,  p.  373. 

2  Note  sur  un  Cas  de  1'  etranglement  interne  de  1'  intestin  grSle  par  un 
diverticule  de  1'  ileon.     Gaz.  des  Hopitaux,  No.  87,  1851. 

*  Amer.  Journal  Med.  Sciences. 


116  INTESTINAL  SURGERY. 

4.  In  the  region  where  these  congenital  causes  are  most  fre- 
quently met  with,  an  occasional  cause  of  intestinal  strangulation, 
viz. :  the  vermiform  appendix,  is  also  found. 

5.  It  would  seem,  therefore,  that  in  the  operation  of  abdominal 
section  for  the  relief  of  acute  intestinal  obstruction,  not  due  to 
intussusception,  and  in  the  absence  of  local  symptoms  calling  for 
the  preferable  exploration  of  other  parts  of  the  abdominal  cavity, 
the  lower  right  quadrant  should  be  selected  as  the  seat  of  incision. 
The  vicinity  of  the  navel  and  the  lower  three  feet  of  the  ileum 
should  then  receive  the  earliest  attention.  If  a  band  is  discov- 
ered it  is  most  likely  to  be  a  persistent  vitelline  duct,  i.  e. : 
Meckel's  diverticulum,  or  an  omphalo-mesenteric  vessel  either  patent 
or  obliterated,  or  both  these  structures  in  continuity.  '  The  section 
of  the  band  may  thus  necessitate  opening  the  intestinal  canal  or  a 
blood-vessel  of  large  size.  Each  of  these  alternatives  is  to  be 
guarded  against,  and  the  removal  of  the  entire  band  is  to  be  sought 
for,  lest  subsequent  adherence  prove  a  fresh  source  of  strangulation. 

According  to  Schroder'  a  diverticulum  is  only  supplied  with  a 
mesentery  when  it  springs  from  the  lateral  aspect  of  the  intestine, 
or  near  the  mesenteric  attachment.  Diverticula  on  the  convex  sur- 
face of  the  bowel  are  free  and  supplied  with  vessels  from  the  intes- 
tinal wall.  Meckel  found  in  several  specimens  a  valve  at  the  junction 
of  the  diverticulum  with  the  bowel,  and  in  one  instance  Phoebus 
found  the  opening  of  the  diverticulum  into  the  bowel  crossed  by 
a  bridge  of  tissue  connecting  its  margins.  The  so-called  false 
diverticula  always  form  on  the  concave  side  of  the  bowel,  and  are 
hernial  protrusions,  their  walls  being  composed  of  peritoneum  and* 
mucous  membrane. 

Greenhow  ^  observed  a  case  where  a  coil  of  the  ileum  had  slipped 
through  a  slit  in  the  mesentery  of  a  diverticulum,  which  in  this  case 
contained  omphalo-mesenteric  vessels,  and  had  become  strangulated 
in  this  position.  Sometimes  a  number  of  congenital  diverticula  are 
found  in  close  proximity  and  at  times  associated  with  other  congen- 
ital defects  of  the  intestine. 

Moore  **  exhibited  to  the  Pathological  Society  of  London  the 
intestines  of  a  man  aged  forty,  showing  three  diverticula  in  the  first 

^  Ueber  Divertikel-Bildung  im  Darmkanale.   Dissertation,  Erlangen,  1854, 

2  The  Lancet,  May  17,  1884. 

3  The  Lancet,  Nov.  10,  1883,  p.  816. 


LIGAMENTOUS  BANDS   OR  DIVERTICULA.  117 

three  feet  of  the  small  intestine,  and  a  congenital  stricture  at  the 
commencement  of  the  jejunum.  The  diverticula  were  each  an  inch 
long  and  about  as  much  in  diameter,  and  were  on  the  mesenteric 
side  of  the  intestine.  Their  walls  consisted  of  all  intestinal  coats, 
and  were  not  mere  hernial  protrusions.  As  long  as  the  free  end  of 
a  diverticulum  remains  unattached,  strangulation  from  this  cause 
cannot  take  place.  Strangulation  can  only  occur  when  both  extremi- 
ties are  fixed,  either  as  a  congenital  condition,  or  when  later,  the  free 
end  becomes  adherent  to  some  fixed  point.  Harris*  showed  a  speci- 
men to  the  Pathological  Society  of  Manchester  of  internal  strangu- 
lation from  a  man  aged  twenty.  There  was  a  whipcord-like  adhe- 
sion about  an  inch  and  a  half  long,  stretching  from  the  tip  of 
Meckel's  diverticulum  to  the  mesentery  of  the  lower  part  of  the 
ileum,  and  through  the  aperture  so  formed  a  loop  of  the  lower  part 
of  the  bowel  had  become  strangulated.  There  had  also  been  a  twist 
of  Meckel's  diverticulum  which  had  ruptured  near  its  base,  and 
death  ensued  from  acute  peritonitis  consequent  upon  faecal  extrava- 
sation. 

That  the  danger  of  perforation  and  peritonitis  from  strangula- 
tion by  a  Meckel's  diverticulum  is  greater  than  when  the  obstruction 
is  caused  by  a  ligamentous  band,  is  shown  by  another  case  reported 
by  Heiberg."  The  patient  was  a  woman,  forty  years  of  age,  who 
died  in  a  few  days  from  an  acute  attack  of  intestinal  obstruction. 
At  the  necropsy  he  found  a  diverticulum  seven  inches  in  length, 
thirty  inches  above  the  ileo-csecal  region,  which  constricted  a  loop  of 
the  ileum  twenty-one  inches  in  length.  The  free  end  of  the  divertic- 
ulum had  passed  between  its  base  and  the  intestine,  and  was  found 
here  with  its  terminal  end  somewhat  dilated.  The  softened  wall  of 
the  diverticulum  was  found  perforated  at  one  point,  which  had  given 
rise  to  faecal  extravasation  and  septic  peritonitis.  A  somewhat 
similar  mechanism  of  strangulation  by  a  diverticulum  was  described 
by  Concato.'*  A  man,  otherwise  in  perfect  health,  was  attacked  by 
acute  intestinal  obstruction  and  died  on  the  fourth  day.  A  loop  of 
the  small  intestine  was  found  constricted  by  a  diverticulum  located 
several  feet  above  the  ileo-caecal  valve,  the  free  end  of  which  had 
insinuated  itself  between  the  junction  of  the  diverticulum  with  the 

1  British  Medical  Journal,  May  28,  1887. 

-  Ueber  innere  Incarcerationen.     Virchow's  Archiv,  B.  54,  p.  30. 

^  Virchow  u.  Hirsch's  Jahresbeiicht,  B.  11,  1871,  p.  155. 


118  INTESTINAL  SURGERY. 

intestine  and  constricted  bowel,  thus  forming  a  firm  knot  around 

the  bowel. 

That  in  most  cases  where  a  diverticulum  causes  an  obstruction 
the  free  end  has  found  a  firm  point  of  attachment  is  well  shown  by 
the  cases  tabulated  by  Cazin.^  He  collected  thirty  cases  of  intestinal 
obstruction  caused  by  diverticula,  and  of  this  number,  in  twenty-five 
the  free  end  was  found  adherent.  A  diverticulum  may  give  rise 
to  symptoms  of  intestinal  obstruction  without  directly  interfering 
with  the  fsecal  circulation.  Such  a  case  has  been  reported  by 
Doran."  A  boy,  four  years  old,  died  on  the  fourth  day  after  an 
attack  of  what  resembled  acute  intestinal  obstruction.  At  the 
necropsy  a  diverticulum  the  size  of  a  pear  was  found  at  the  junction 
of  the  ileum  with  the  jejunum,  which  contained  a  pea.  The  foreign 
body  had  caused  ulcerative  inflammation  and  perforation  of  the 
diverticulum  and  death  from  perforative  peritonitis.  The  divertic- 
ulum was  supplied  with  a  mesentery  and  its  walls  were  composed  of 
all  the  tunics  of  the  bowel. 

Southey^  alludes  to  another  variety  of  obstruction  caused  by  a 
diverticulum,  viz. :  contraction  of  the  intestine  at  a  point  where  the 
diverticulum  is  given  off.  He  gives  a  description  of  two  such 
specimens.  In  one  the  diverticulum  formed  a  band  the  size  of  a 
goose-quill,  and  extended  from  a  point  two  feet  above  the  ileo-csecal 
valve  to  the  abdominal  wall  two  inches  below  the  umbilicus.  The 
ileum  just  above  the  diverticulum  was  so  constricted  as  only  to  admit 
the  tip  of  the  little  finger,  and  at  the  point  of  constriction  the  coats 
of  the  intestine,  both  mtiscular  and  mucous,  were  ulcerated  through, 
the  continuity  of  the  intestine  being  preserved  only  by  the  thickened 
peritoneum.  In  the  second  case  tbe  bowel,  at  a  point  about  eighteen 
inches  above  the  ileo-csecal  valve,  was  abruptly  constricted  to  a 
diameter  of  about  half  an  inch,  and  a  diverticulum  five  inches  long, 
havino-  a  calibre,  at  first  large  enough  to  admit  the  little  finger,  passed 
from  the  intestine  and  was  attached  at  its  extremity  to  the  umbilicus. 
In  this  case  death  was  hastened  by  acute  diffuse  peritonitis.  That 
not  all  constricting    bands   are  the  remains   of  the  vitelline  duct, 


1  Etude  anatomique  et  pathologique  sur  les  diverticules    de  1'  intestin. 
Thhse.  Paris,  1862. 

2  Case   of  Acute  Intestinal  Obstruction;  perforation  of   a  diverticulum. 
Transactions  of  the  Pathological  Society,  Vol.  XXIV,  p.  122. 

2  Transactions  of  the  Clinical  Society  of  London.     Vol.  V,  1872. 


LIGAMENTOUS  BANDS   OR   DIVERTICULA.  119 

requires  no  argument  in  speaking  of  the  operative  treatment  of 
obstruction  from  constriction  by  bands ;  but  the  possibility  of  mistak- 
ing a  peritoneal  fold  enclosing  unobliterated  umbilical  vessels  for  an 
ordinary  cicatricial  band  must  be  remembered  and  the  necessary 
sections  of  the  band  made  between  ligatures,  i  If  a  Meckel's 
diverticulum  is  formd  to  be  the  cause  of  obstruction,  this  appendage 
should  always  be  resected  by  ligating  it  at  its  base  with  a  rubber 
ligature,  and  after  the  incision,  the  end  invaginated  and  the  invagi- 
nation maintained  by  a  few  stitches  of  the  continued  suture.  /Weir 
recommends  in  the  excision  of  a  constricting  diverticulum  to  apply 
a  ligature  and  after  cutting  it  ofP,  to  stitch  the  peritoneal  surface 
over  the  divided  muscular  and  mucous  coat;  but  when  the  divertic- 
ulum is  nearly  of  the  same  diameter  as  the  intestine  from  which  it 
springs,  such  a  course  would  not  afford  ample  protection  against 
perforation. 

Glutton^  related  a  case  to  the  Clinical  Society  of  London,  of 
intestinal  obstruction  caused  by  a  diverticulum,  successfully  treated 
by  operation.  The  patient  was  a  boy  aged  ten  years,  who  had 
suffered  on  several  occasions  from  colicky  pains  lasting  for  two  or 
three  days  and  always  terminating  with  a  copious  evacuation  from 
the  bowels.  This  attack  commenced  with  vomiting  and  great  pain 
in  the  abdomen,  which  persisted  in  spite  of  opium  treatment  for 
four  days,  when  he  was  brought  into  the  hospital  and  at  once 
submitted  to  an  operation.  On  opening  the  abdomen  through  the 
linea  alba  a  collapsed  portion  of  bowel  was  soon  found,  and,  on 
bringing  it  to  the  surface,  a  tight  ring-like  cord  could  be  felt  and 
seen  to  be  the  cause  of  strangulation.  The  cord  was  divided 
between  two  pairs  of  forceps  and  each  end  tied  with  a  catgut 
ligature.  This  step  of  the  operation  relieved  the  bowel  from 
strangulation.  On  making  an  investigation  as  to  the  nature  of  the 
band  divided  it  was  found  that  one  of  the  ligatures  was  situated  at 
the  extreme  end  of  a  diverticulum  two  inches  in  length,  and  the 
other  was  placed  upon  the  wall  of  the  same  loop  of  intestine  at  a 
distance  of  about  six  inches.  A  portion  of  bowel  of  about  three 
inches  in  length  between  these  two  points  of  attachment  was  the 
part  strangulated,  and  was  of  an  extremely  dark  color  with  a  deep 
sulcus  at  each  side.  The  boy  made  an  uninterrupted  and  rapid 
recovery. 

1  The  Lancet,  May  17,  1884. 


120  INTESTINAL   SURGERY. 

Cltitton  explained  the  condition  as  follows:  "The  vitelline 
duct  had  obliterated  at  the  umbilicus,  and  set  free  from  the  abdominal 
wall,  but  remaining  patent  towards  the  ileum  the  lower  end  had 
become  a  pouch-like  diverticulum  from  the  intestine.  This  divertic- 
ulum terminating  in  a  pointed  extremity  or  cord  part  also  of  the 
vitelline  duct  which  had  been  obliterated  had  remained  floating 
about  among  the  intestines  till  it  became  attached  to  the  bowel  in 
contact  with  it.  The  gut  between  the  two  points  of  attachment  had 
slipped  beneath  the  cord  which  united  them,  and  being  unable  to 
extricate  itself  had  become  strangulated." 

Another  interesting  case  of  intestinal  strangulation  caused  by  a 
Meckel's  diverticulum  and  successfully  treated  by  laparotomy  is 
reported  by  McGill.'  The  patient  was  a  man,  aged  thirty  years, 
who  had  suffered  from  acute  intestinal  obstruction  for  nine  days. 
The  abdomen  was  very  much  distended  at  the  time  of  operation.  As 
the  seat  of  obstruction  could  not  be  readily  found  by  intra-abdom- 
inal palpation,  partial  extrusion  of  intestines  was  allowed  to  take 
place,  but  as  soon  as  three  feet  of  the  small  intestines  had  escaped 
the  junction  of  the  distended  with  the  empty  intestine  came  into 
view.  At  this  point  a  Meckel's  diverticulum,  much  dilated  and 
about  six  inches  in  length,  was  seen,  passing  downwards  and 
forwards,  to  be  attached  to  the  fundus  of  the  bladder.  A  loop  of 
collapsed  intestine  passed  under  the  diverticukim,  the  obstruction 
being  caused  by  the  twisting  of  the  bowel  at  the  point  where  the 
diverticulum  was  attached.  Slight  traction  proved  efficient  in 
releasing  the  bowel  from  the  grasp  of  the  diverticulum,  and  as  soon 
as  this  was  accomplished,  the  empty  portion  of  the  bowel  became 
filled  with  the  intestinal  contents.  Nothing  was  done  to  the 
diverticulum.  On  the  tenth  day  a  small  faecal  fistula  formed  at 
the  lower  angle  of  the  wound ;  this  continued  two  weeks,  when  the 
discharge  ceased  and  the  patient  recovered  without  any  further 
untoward  symptoms.  The  author  believes  that  this  is  the  first 
recorded  case  where  the  free  end  of  the  diverticulum  had  its  attach- 
ment to  the  fundus  of  the  bladder.  There  can  be  but  little  doubt 
that  the  fsecal  fistula  in  this  case  was  caused  by  a  perforation  of  the 
diverticulum,  an  accident  which  might  have  proved  fatal  if  extrava- 

^  Remarks  on  a  Case  of  Acute  Intestinal  Obstruction  due  to  the  Presence 
of  a  Meckel's  Diverticulum  Successfully  Treated  by  Laparotomy.  British 
Medical  Journal,  Jani^iry  14,  1888. 


NON-MALIGNANT  STENOSIS.  1-1 

sation  had  taken  place  into  the  peritoneal  cavity,  and  which  might 
have  been  avoided  had  the  diverticulum  been  removed,  w^hich  would 
also  have  protected  the  patient  with  certainty  against  a  possible 
recurrence  in  the  future,  of  obstruction  from  the  same  cause. 

6.     Non-malignant  Stenosis. 
1.    Congenital. 

Congenital  narrowing  of  the  bowel  varies  in  degree  from  a 
slight  contraction  to  complete  atresia.  In  my  experiments  on 
animals  I  have  shown  that  when  the  lumen  of  the  small  intestines 
is  diminished  one-half  in  size  by  partial  enterectomy  and  suturing 
of  the  wound  in  a  direction  parallel  to  the  long  axis  of  the  bowel, 
the  function  of  the  bowel  is  not  impaired,  and  obstruction  does  not 
occur,  but  if  the  stenosis  is  earned  beyond  this  point  there  is  great 
danger  of  obstruction  arising  from  accumulation  of  solid  intestinal 
contents  on  the  proximal  side  of  the  stenosis.  The  same  holds  true 
of  congenital  stenosis  of  the  small  intestines.  Even  if  the  narrow- 
ing is  considerable  no  serious  symptoms  are  produced  until  some 
foreign  bodies  collect  above  the  seat  of  constriction  and  cause 
obstruction  from  coprostasis. 

Legg '  reports  an  exceedingly  interesting  case  where  a  congeni- 
tal stenosis  of  the  ileo-caecal  opening  led  to  chronic  obstruction, 
dilatation  of  ileum,  and  finally  to  perforation  into  the  ascending  colon. 
A  female  twenty-six  years  of  age  was  admitted  into  the  hospital 
April,  1858.  She  stated  that  since  she  was  five  years  of  age  she  had 
suffered  from  occasional  attacks  of  colic,  perhaps  five  times  during 
a  year,  attended  by  constipation  and  vomiting.  After  such  an  attack 
eight  years  ago  a  number  of  cherry-stones  passed  with  the  faeces. 
Kecently  the  attacks  became  more  frequent,  and  the  last  was  so 
severe  that  she  found  it  necessary  to  seek  admission  into  the  hospital. 
When  admitted  she  presented  many  symptoms  of  obstruction.  In 
the  right  iliac  fossa  on  percussion  a  dry  crackling  sound  could  be 
heard  and  felt.  In  a  few  days  she  again  passed  a  few  cherry  and 
plum  stones  and  felt  relieved.  She  was  given  five  gutta-percha 
pills,  which  never  passed  through.  She  left  the  hospital  improved, 
and  was  not  seen  again  until  six  years  later.    At  this  time  she  again 


1  Congenital  Constriction  of  the  Ileo-csecal  Orifice  and  Dilatation  of  the 
Ileum;  Retention  of  Fruit-stones  in  Jejunum  and  Ileum.  Trans.  Pathological 
Society,  Vol.  XXI,  p.  1 71 .  ^ 


122  INTESTINAL  SURGERY. 

suffered  from  well-marked  symptoms  of  intestinal  obstruction,  and 
during  the  first  few  days  vomited  a  number  of  cherry  and  plum 
stones,  and  a  black  round  mass  which,  on  cutting,  was  believed  to  be 
one  of  the  gutta-percha  pills  which  she  had  taken  six  years  before. 
Below  the  umbilicus  the  same  crackling  sound  could  be  heard  and 
felt  as  before.  The  symptoms  of  obstruction  gradually  became 
worse,  and  a  few  weeks  after  admission  she  died.  At  the  necropsy 
the  entire  colon  was  found  empty  and  contracted,  the  ileum  very 
much  dilated,  so  much  so  that  the  lower  portion  measured  seven 
inches  in  circumference.  On  opening  it  fluid  f feces  and  a  few  fruit- 
stones  escaped.  Ileo-csecal  orifice  contracted  so  that  it  would  admit 
only  a  number  nine  catheter.  Above  the  ileo-cfecal  valve  a  communi- 
cating bimucous  fistulous  opening  the  size  of  a  quarter  of  a  dollar 
had  formed  between  the  colon  and  ileum,  and  a  little  distance  above 
this  point,  another  but  smaller  opening  had  formed  in  the  same  man- 
ner by  adhesion  and  perforation.  In  the  small  intestines  a  pint  of 
cherry-stones  were  found,  all  of  them  covered  with  a  black  crust, 
which  on  examination  proved  to  contain  iron.  The  author  could 
find  in  the  literature  only  six  cases  of  non-malignant  stenosis  of  the 
ileo-csecal  opening.  In  Schroeder  van  der  Kolk's  case  the  opening 
was  even  smaller,  and  in  the  lower  portion  of  the  ileum,  which  was 
enormously  dilated,  a  large  mass  of  cherry-stones  and  fragments  of 
bone  were  found. 

Bourdon'  observed  another  case  of  congenital  stenosis  of  the 
ileo-caecal  orifice  like  that  narrated  by  Dor."  The  patient,  a  man 
thirty-two  years  of  age,  had  suffered  for  a  month  from  pain  in 
the  abdomen,  nausea  and  vomiting.  The  bowels  were  moved  with 
difiicuity  by  cathartics.  On  examination  nothing  could  be  found 
except  a  doughy  condition  of  the  middle  portion  of  the  abdomen, 
where  percussion  revealed  also  a  certain  degree  of  dullness.  He 
remained  two  weeks  in  the  hospital  without  any  improvement  being 
noticeable,  when  he  left,  but  returned  three  days  later.  At  this  time 
an  irregular,  uneven  swelling  could  be  distinctly  felt  in  the  right 
groin.  The  swelling  rapidly  increased  in  size  and  the  patient  died 
in  a  few  days  of  peritonitis.  At  the  necropsy  the  small  intestines 
were  found  very  much  distended,  colon  and  rectum  contracted  and 
empty.     Just  above  the  ileo-csecal  valve  the  ileum  was  distended  to 

>  L'Union  M^dicale  67,  1856.     Schmidt's  Jahrbttcher,  B.  96,  p.  204, 
2  Gaz.  Med.  de  Paris,  No.  9,  1835. 


NON-MALIGNANT  STENOSIS.  123 

the  size  of  a  fcetal  head  adherent  to  the  posterior  abdominal  wall, 
mesentery  and  intestinal  coils.  The  walls  of  this  pouch  were  thick- 
ened and  of  a  brown  color.  When  opened  it  was  found  to  contain 
one  hundred  and  twenty  plum-stones  and  ninety-two  lead  bullets. 
The  ileo-csecal  valve  was  nearly  closed  and  was  permeable  only  to 
fluids.  The  patient  had  probably  swallowed  the  bullets  to  overcome 
obstinate  constipation. 

In  all  of  these  cases  of  congenital  stenosis  no  symptoms  were 
caused  by  the  congenital  defect  until  the  foreign  bodies  which 
collected  above  it,  finally  produced  death  from  intestinal  obstimction 
or  perforative  peritonitis.  The  clinical  history  in  each  case  distinctly 
points  to  aggravation  of  the  obstruction  by  the  occurrence  of  copros- 
tatis  above  the  seat  of  stenosis.  The  surgical  treatment  in  such 
cases  consists  in  removing  the  impacted  substances  through  an 
incision  above  the  stenosis,  and  after  clearing  the  bowel  of  its  con- 
tents uniting  it  with  a  similar  incision  in  the  bowel  below  the  obstruc- 
tion, by  lateral  apposition  with  decalcified  perforated  bone  plates, 
thus  establishing  a  free  anastomosis  between  the  bowel  above  and 
below  the  obstruction,  and  excluding  at  the  same  time  permanently 
from  the  intestinal  circulation,  the  contracted  portion  of  the  intestine. 
Excision  and  restoration  of  the  continuity  of  the  intestinal  canal  by 
circular  enterorrhaphy  can  only  be  thought  of  in  case  perforation 
has  taken  place. 

2.     Acquired  or  Cicatricial. 

Cicatricial  stenosis  of  the  intestines  is  one  of  the  remote  conse- 
quences of  deep  ulcerative  lesions,  such  as  are  caused  by  dysentery, 
typhlitis  stercorals,  tuberculosis,  and  ileo-typhus.  The  cicatrix 
which  forms  during  the  reparative  stage  of  the  ulceration  contracts 
slowly  and  gives  rise  to  stenosis  and  chronic  intestinal  obstruction. 
As  in  cases  of  congenital  stenosis,  the  obstruction  often  becomes 
complete  and  gives  rise  to  acute  symptoms  when  foreign  bodies  or 
solid  ffBces  become  impacted  above  the  seat  of  constriction.  Not 
infrequently  the  causes  which  have  led  to  cicatricial  stenosis  are 
located  at  the  same  time  or  appear  successively  in  different  parts  of 
the  intestine,  producing  consequently  also  multiple  strictures. 

Sharkey^  presented  to  the  Pathological  Society  of  London  a 
specimen  of  multiple  strictures  of  the  ileum,  taken  from  a  woman 

1  The  Lancet,  May  24,  1884, 


124  INTESTINAL  SURGERY. 

thirty-three  years  of  age,  who  had  suffered  frequently  from  indi- 
gestion and  vomiting.  The  immediate  cause  of  death  was  facial 
erysipelas.  The  lower  two-thirds  of  the  small  intestines  exhibited 
numerous  ulcers  apparently  healed.  They  were  so  near  together 
and  produced  such  marked  constriction  that  the  appearance  of  a 
succession  of  pouches  was  simulated.  There  were  no  distinct  evi- 
dences of  tuberculosis  in  the  intestine  or  any  of  the  other  organs. 
In  the  discussion  which  followed  the  demonstration  of  this  speci- 
men Treves  spoke  of  other,  somewhat  similar,  recorded  cases  in  which 
typhoid  fever  and  tuberculosis  seemed  to  be  excluded.  Treves  ^  has 
described  another  cause  of  cicatricial  stenosis.  He  has  met  with 
such  cases  in  patients  who  suffered  from  strangulated  hernia,  when 
the  prolonged  compression  during  the  strangulation  had  produced  a 
circumscribed  gangrene  of  the  mucous  coat.  In  all  of  the  recorded 
cases  the  patients  appear  to  have  recovered  well  from  the  hernial 
trouble,  and  after  a  varying  time  to  have  gradually  developed  symp- 
toms of  cicatricial  stenosis  of  the  small  intestines. 

Another  form  of  cicatricial  stenosis  of  the  intestines  is  caused 
by  the  formation  of  a  cicatrix  in  the  peritoneal  coat,  as  the  result  of 
a  circumscribed  plastic  peritonitis.  In  this  form  the  mucous  and 
muscular  coats  are  intact,  but  the  bowel  is  narrowed  and  puckered 
by  a  band  of  cicatricial  tissue.  Cicatricial  stenosis  of  the  colon  is 
caused  most  frequently  by  dysentery,  while  the  same  condition  in 
the  rectum  often  appears  as  a  syphilitic  lesion.  In  the  treatment  of 
cicatricial  stricture  of  the  intestine  the  question  of  resection  again 
confronts  us.  Maydl "  reports  two  successful  cases  of  circular  resec- 
tion and  suturing  for  cicatricial  stricture  of  the  ileo-csecal  valve.  In 
the  first  case  he  relieved  the  obstruction  by  an  enterotomy,  and  a 
year  later  excised  the  constricted  portion  of  the  caecum  and  united 
the  ileum  with  the  ascending  colon.  In  the  second  case  the  general 
condition  of  the  patient  warranted  a  radical  operation,  which  con- 
sisted in  the  excision  of  the  caecum  and  immediate  restoration  of  the 
continuity  of  the  intestinal  canal  by  suturing.  The  conditions  in 
these  cases  for  circular  enterorrhaphy  were  unusually  favorable,  as 
the  colon  must  have  been  in  a  contracted  state,  while  the  lower  por- 

'  Intestinal  Obstruction  that  May  Follow  after  Hernia.      The  Lancet. 

^Ueber  einen  zweiten  Fall  von  narbiger  Striktur  der  Ileo-cascal  Klappe 
durch  cirkulare  Darmresektion  und  Naht  gebeilt.  AUgem.  Wiener  Med. 
Zeitungr.  No.  17,  1881. 


NON-MALIGNANT  STENOSIS.  125 

tion  of  the  ileum,  from  the  prolonged  obstruction,  was  much  dilated, 
BO  that  the  lumina  of  the  resected  ends  must  have  been  nearly  equal 
in  size.  Both  patients  recovered.  In  the  first  case,  where  the 
patient  suffered  all  the  inconveniences  of  an  artificial  anus  for  one 
year,  a  radical  operation  by  an  ileo- colostomy  could  have  been  made 
with  no  more  risk  than  was  incident  to  the  enterotomy,  and  would 
have  thus  avoided  the  necessity  of  establishing  an  artificial  anus  and 
of  performing  a  second  operation.  Where  no  gangrene  or  perfora- 
tion is  present,  I  should  strongly  recommend  the  substitution  of 
intestinal  anastomosis  for  resection  and  circular  enterorrhaphy.  In 
cases  of  mtdtiple  stricture  where  they  involve  a  limited  area  of  the 
intestine  an  anastomosis  should  be  made  between  the  intestines  at  a 
point  above  the  first  and  below  the  last  stricture,  excluding  perma- 
nently the  intervening  portion  from  the  faecal  circulation. 

Eddowes '  operated  on  a  case  of  intestinal  obstruction  due  to  a 
cicatrical  stricture  where  the  symptoms  were  promptly  relieved  by 
the  formation  of  an  artificial  anus,  and  the  patient  recovered  with  a 
permanent  fistula.  A  woman  forty-six  years  old,  was  seized  nineteen 
days  before  the  operation  with  abdominal  pain,  which  had  persisted 
ever  since.  For  twelve  days  there  had  been  no  action  of  the  bowels 
without'  enemata;  complete  constipation  had  existed  for  five  days. 
There  was  no  history  of  syphilis,  tuberculosis  or  cancer.  The 
abdomen  was  distended,  but  soft  and  free  from  tenderness ;  the  walls 
were  very  thin,  and  moving  coils  of  small  intestine  were  plainly 
seen.  The  abdomen  was  opened  by  an  incision  four  inches  long  in 
the  median  line  between  umbilicus  and  pubes.  A  small  quantity  of 
peritoneal  fluid  mixed  with  lymph  escaped,  and  the  abdominal  con- 
tents appeared  congested.  A  stricture  of  the  small  intestine  was 
soon  found,  forming  a  complete  obstruction,  impermeable  even  to 
flatus.  An  artificial  anus  was  formed  at  the  lower  extremity  of  the 
wound,  about  two  inches  from  the  pubes.  The  operation  was 
followed  by  a  great  sense  of  relief.  The  lower  portion  of  the  wound 
suppurated  on  account  of  escape  of  fseces,  otherwise  the  recovery 
progressed  favorably.  Seven  months  after  the  operation  the  patient 
was  in  perfect  health,  had  gained  considerably  in  weight,  and  was 
able  to  go  about  her  household  work  as  before.  The  bowels  acted 
very  regularly  every  morning,  the  motion  was  gradually  formed,  and 

1  British  Medical  Journal,  July  24,  1886. 


126  INTESTINAL   SURGERY. 

in  this  case  she  had  very  good  control,  but  she  was  unable  to  con- 
trol liquid  motions  and  flatus.  On  introducing  the  finger,  it  was 
felt  to  be  distinctly  grasped  by  a  sphincter. 

i  Although  the  symptoms  of  obstruction  were  successfully  re- 
moved by  establishing  an  artificial  anus  in  the  median  line,  this 
course  of  practice  is  open  to  serious  objections.  An  artificial  anus 
should  never  be  established  in  the  median  incision,  as  the  contact  of 
faeces  with  the  wound  necessarily  prevents  healing  by  first  intention. 
If  such  a  course  is  contemplated  after  the  abdomen  has  been  ex- 
plored through  a  median  incision,  a  small  incision  for  the  enterotomy 
should  be  made  in  one  of  the  inguinal  regions,  and  the  median 
incision  closed  and  dressed  separately.  >,  In  following  such  a  course 
the  large  incision  will  heal  by  primary  union  and  the  abdomen  can 
subsequently  be  opened  again  to  better  advantage  through  the 
median  line  for  the  performance  of  a  radical  operation.  This,  like 
all  similar  cases,  would  have  been  a  proper  subject  for  intestinal 
anastomosis.  • 

In  non-malignant  stricture  of  the  colon,  colectomy  and  circular 
enterorrhaphy  should  be  done  in  all  cases  where  approximation  of 
the  bowel  ends  is  possible.  In  multiple  strictures  of  this  portion 
of  the  intestinal  canal  resection  is  inapplicable,  and  the  obstruction 
can  only  be  rendered  harmless  and  the  continuity  of  the  intestinal 
canal  restored  by  lateral  implantation  or  by  establishing  an  intesti- 
nal anastomosis. 

Coupland  and  Morris '  have  collected  a  number  of  cases  of  stric- 
ture of  the  intestine,  and  in  commenting  on  the  material,  assert  that 
in  three-fourths  of  all  the  cases,  the  disease  affected  the  lower  part 
of  the  bowel,  being  about  equally  divided  between  the  rectum  and 
the  sigmoid  flexure.  "With  few  exceptions  strictures  are  located 
below  the  csecum.  In  many  of  the  fatal  cases  death  occurred  from 
perforation  either  above  the  stricture  or  in  the  caecum.  From 
Bryant's  investigations  it  appears  that  one-third  of  the  cases  of 
stricture  of  the  rectum  or  lower  bowel  are  not  malignant,  a  most 
important  practical  point  with  regard  to  treatment.  He  lays  down 
the  following  general  rule  for  performing  lumbar  colotomy  in  cases 
of  stricture  of  the  rectum:  ''In  all  cases  of  cancerous  stricture  of  the 
rectum  or  colon,  including  the  annular,  which  are  not  amenable  to 

'  On  Strictures  of  the  Intestine;  with  Remarks  upon  Statistics  as  a  Guide 
to  Diagnosis  and  Treatment,  1878. 


TUMORS.  127 

lumbar  colectomy  or  anal  excision,  right  or  left  Inmbar  colotomy  is 
strongly  to  be  advocated,  with  the  well-grounded  hope  of  relieving 
suffering,  retarding  the  progress  of  the  disease;  and  prolonging  life 
even  for  five  or  six  years.  To  secure  these  advantages  it  is  neces- 
sary for  the  operation  to  be  performed  before  the  pernicious  effects 
of  obstruction  occur." 

Against  lumbar  colotomy  I  have  already,  in  another  part  of  the 
paper,  entered  my  protest,  and  in  cases  of  inoperable  carcinoma  of 
the  rectum  producing  evidences  of  obstruction,  I  wish  to  call  atten- 
tion to  the  method  of  operating  devised  by  Madelung.'  In  cases  of 
malignant  stricture  of  the  rectum,  where  it  is  desirable  to  exclude 
the  part  at  and  below  the  seat  of  obstruction  completely  and  per- 
manently from  the  fsecal  circulation,  he  opens  the  abdomen  by  a 
lateral  incision  and  divides  the  colon  completely  in  a  transverse 
direction,  and  as  low  down  as  possible.  The  distal  end  is  closed  by 
invagination  and  two  rows  of  sutures,  and  dropped  into  the  peri- 
toneal cavity,  while  the  proximal  end  is  sutured  into  the  wound. 
This  operation  secures  absolute  physiological  rest  for  the  diseased 
portion  of  the  bowel  and  is  less  likely  to  be  followed  by  prolapse,  as 
is  the  case  when  the  bowel  is  simply  stitched  into  the  wound  and 
opened.  Anal  extirpation  of  the  rectum,  both  for  cicatricial  and 
carcinomatous  stenosis,  should  always  be  practiced  when  the  obstruc- 
tion and  the  local  conditions  which  have  caused  it,  can  be  removed 

by  this  method. 

7.    Tumors. 

A  tumor  can  give  rise  to  intestinal  obstruction  in  different  ways, 
according  to  its  location  and  anatomico-pathological  character.  A 
tumor  or  swelling  outside  of  the  intestinal  tube  may  cause  obstruc- 
tion by  compression.  A  polypoid  growth  springing  from  the  mucous 
or  sub-mucous  tissue  interrupts  the  fsecal  circulation  either  by 
blocking  the  lumen  of  the  bowel  by  its  size,  or  by  causing  an 
invagination  or  flexion.  A  circular  carcinoma  produces  a  stenosis 
which  leads  to  chronic  obstruction,  but  which  is  frequently  the 
indirect  cause  of  acute  intestinal  obstruction  when  either  by  addi- 
tional pathological  changes  at  the  seat  of  the  malignant  disease,  or 
by  the  accumulation  of  foreign  bodies  or  solid  fsecal  masses  above 
the  seat  of  constriction  the  faecal  circulation  is  completely  arrested. 

^  Modification  der  Colotomie  wegen  Carcinoma  Recti.  Verb,  der  Deutschen 
Gesellschaf t  f.  Chirurgie,  1884. 


128  INTESTINAL  SURGERY. 

1.    Non-Malignant  Tumors. 

Benign  polypoid  tumors  seldom  attain  a  sufficient  size  to  give 
rise  to  intestinal  obstruction,  unless  they  cause  additional  mechanical 
disturbance,  such  as  invagination  or  flexion,  conditions  which  have 
already  been  alluded  to.  If  the  tumor  alone  is  the  cause  of  obstruc- 
tion it  is  removed  by  laparo-enterotomy.  A  few  cases  have  recently 
been  reported  where  the  obstruction  was  caused  by  cysts.  In  Buch- 
wald's^  case  the  symptoms  of  obstruction  were  acute,  and  laparotomy 
was  performed  on  the  third  day.  The  patient  was  a  boy  who  had 
previously  been  in  good  health.  As  soon  as  the  peritoneal  cavity 
was  opened,  two  cysts  attached  to  the  small  intestine  presented 
themselves  in  the  wound.  As  the  cysts  had  produced  a  sharp  flexion, 
0  cm.  of  the  bowel,  including  the  cysts,  were  resected  and  the  ends 
united  by  circular  suturing.  Twenty-seven  hours  after  the  operation 
the  patient  died.  The  necropsy  showed  that  the  resected  piece  was 
taken  from  the  jejunum  one-half  metre  below  the  duodenum.  One 
cyst  measured  17  and  the  other  10  cm.  in  diameter.  The  walls  of 
the  cysts  were  white  and  very  thin.  The  microscopical  examination 
showed  that  they  were  composed  of  the  same  tunics  as  the  bowel, 
but  the  mucous  membrane  was  atrophied  and  contained  no  glands. 
The  cysts  communicated  with  each  other  and  the  lumen  of  the 
bowel.  The  latter  was  not  diminished  in  size.  The  cysts  contained 
a  yellowish  fluid,  with  a  strong  odor  of  acetone.  Under  the  micro- 
scope the  contents  showed  cylindrical  cells  in  a  state  of  fatty 
degeneration,  cholesterine  crystals,  granules  of  leucin,  fat  globules, 
and  rod- shaped  bacteria,  but  no  intestinal  contents.  He  believes 
that  the  cysts  had  no  connection  whatever  with  the  vitelline  duct. 

Kulenkampff  ^  reports  the  case  of  a  child  three  years  old  that 
had  suffered  occasionally  from  colic  and  constipation,  and  was 
attacked  suddenly  with  symptoms  indicative  of  acute  intestinal 
obstruction.  Abdomen  somewhat  tympanitic,  but  no  swelling  could 
be  made  out  by  percussion  and  palpation.  Tenderness  and  slight 
dullness  in  the  right  inguinal  region.  The  boy  died  on  the  second 
day.  The  autopsy  revealed  as  the  cause  of  death  a  cyst  in  the  region 
of  the  caecum.     The  cyst  was  as  large  as  a  man's  fist,  and  had  thin, 

'  Ueber    Darmcysten    als    Ursache    eines    kompleten  Darmverschlusses. 
Deutsche  Med.  Wochenschrift,  No.  40,  1887. 

Ein  Fall  von  Entero-kystom.  Tod  durch  Darmverschlingung.  Central- 
blatt  f.  die  gesammte  Medicin,  IJJo.  42,  1883. 


TUMORS.  129 

almost  transparent  walls.  It  showed  several  depressions  which 
gave  it  the  appearance  of  being  composed  of  three  or  four  parts. 
It  was  located  in  the  mesentery  of  the  ileiim,  about  40  cm.  above 
the  ileo-csecal  valve.  It  did  not  communicate  with  the  lumen  of  the 
bowel,  and  contained  a  thin  chocolate-colored  fluid.  The  mesentery 
at  this  point  was  drawn  out  like  a  string  and  encircled  a  loop  of  the 
ileum.  Above  this  point  the  bowel  was  greatly  distended.  He 
believed  with  Roth  ^  that  the  cyst  was  congenital  and  had  developed 
from  a  diverticulum  of  the  ileum.  As  a  rule  such  cysts  are  located 
on  the  convex  side  of  the  bowel,  but  in  this  instance  it  occupied  a 
position  opposite.  At  first  sight  the  cyst  appeared  like  a  greatly 
distended  loop  of  intestine.  As  in  both  these  cases  the  cyst  had 
produced  intestinal  obstruction  by  secondary  mechanical  conditions, 
the  operative  treatment  of  the  obstruction  would  include  the  removal 
of  the  primary  cause  and  the  correction  of  the  secondary  mechanical 
difficulties.  This  would  include  resection  of  the  bowel  at  the  seat 
of  obstruction  including  the  tumor,  and  restoration  of  the  continuity 
of  the  intestinal  canal  by  circular  suturing. 

2.    Malignant  Tumors. 

Malignant  stenosis  of  the  intestines  may  be  caused  either  by  a 
sarcoma  or  carcinoma,  of  which  the  former  is  more  frequent  above 
and  the  latter  below  the  ileo-csecal  valve.  A  sarcoma  in  the  intestine, 
as  in  any  other  organ,  primarily  starts  from  an  embryonal  matrix 
of  connective  tissue,  and  hence  it  always  has  its  starting-point  in  the 
wall  beneath  the  mucous  membrane;  while  carcinoma,  being  an 
atypical  proliferation  of  epithelial  cells,  either  commences  in  the 
mucous  membrane  or  its  glandular  appendages. 

a.     Sarcoma. 

Nicolaysen^  reports  an  exceedingly  interesting  case  of  enterec- 
tomy  for  a  sarcomatous  stenosis  of  the  small  intestine.  The 
patient  was  twenty-eight  years  of  age.  A  firm  nodulated,  kidney- 
shaped  tumor  could  be  felt  in  the  abdomen  below  the  umbilicus. 
The  tumor  was  first  noticed  six  months  before,  when  it  was  as  large 
as  a  hen's  egg.     In  the  morning  the  tumor  usually  could  be  felt 

1  Virchow's  Archiv.     B.  LXXXVI,  p.  311. 

2  Myosarkom  des  Dtinndarmes.     Extirpation  mit  Darmreseclition.     Cen- 
tralblatt  f.  die  ges.  Medicin,  No.  28,  1886. 

9 


130  INTESTINAL  SURGERY. 

under  the  costal  arch,  while  during  the  day  it  descended  into  the 
hypogastric  region  where  it  always  caused  more  pain.  As  the  symp- 
toms of  obstruction  gradually  increased  in  severity  and  did  not  yield 
to  ordinary  treament  laparotomy  was  performed.  Median  incision 
14  cm.  long.  It  was  found  somewhat  difficult  to  bring  the  tumor 
forward  into  the  wound.  The  tumor  occupied  the  mesenteric  side  of 
the  bowel  and  behind  it  a  number  of  enlarged  lymphatic  glands 
could  be  felt.  Eighteen  centimetres  of  intestine,  including  the  tumor 
and  a  triangular  piece  of  mesentery  were  excised,  and  the  ends  of  the 
intestine  united  with  sutures,  embracing  only  serous  and  muscular 
coats,  whereupon  the  proximal  end  was  invaginated  to  the  extent  of 
2  cm.  and  the  invagination  retained  with  five  Lembert  sutures,  over 
which  the  peritoneum  was  once  more  stitched  with  a  continued 
suture  of  fine  catgut.  The  mesenteric  wound  was  also  closed  by 
suturing.  The  tumor  consisted  of  several  nodules  the  size  of  a  goose- 
egg,  which  had  perforated  the  intestine.  Microscopical  examination 
of  the  tumor  and  lymphatic  glands  showed  sarcomatous  tissue.  The 
patient  recovered. 

Bessel-Hagen '  described  a  somewhat  similar  specimen  which  he 
found  in  a  child.  A  boy  seven  years  old,  after  a  trauma,  sufPered 
from  a  rapidly  growing  tumor  in  the  abdomen,  which  resulted  in 
death  from  marasmus  in  four  months.  At  the  autopsy  a  large 
sarcoma  of  the  jejunum  was  found  which  had  perforated  into  the  gut 
by  necrotic  destruction  of  the  interior  of  the  tumor.  Microscopic 
examination  proved  it  to  be  a  small-celled,  round-celled  sarcoma 
which  had  originated  in  the  submucosa  of  the  jejunum.  Multiple 
metastasis  in  kidneys,  on  back  and  in  the  lymphatic  glands.  Peri- 
tonitic  adhesions  had  caused  flexion  of  the  intestine  below  the  tumor, 
and  dilatation  of  the  proximal  portion  from  obstruction  thus  pro- 
duced. As  a  sarcoma  of  the  intestine  only  gives  rise  to  symptoms 
of  obstruction,  and  consequently  comes  under  surgical  treatment, 
usually  after  extensive  infiltration  of  the  mesentery  and  retro- 
peritoneal tissues  has  taken  place,  it  is  questionable  if  it  is  prudent 
to  attempt  a  radical  operation,  as  in  case  the  patient  recovers  from 
the  operation,  an  early  recurrence  is  almost  inevitable.  If  a  suffi- 
ciently early  diagnosis  were  possible,  resection  could  be  made  with  a 
fair  prospect  of  a  permanent  result;  but  if  the  infection  has  extended 

1  Ulceroses  Sarcom  des   Jejunum   bei   einem  Kinde.     Virchow's  Archiv. 
B.  XCIX,  Heft  1. 


TUMORS.  131 

to  the  tissues  around  the  bowel,  it  is  more  judicious  to  leave  the 
sarcoma  and  to  exclude  the  obstruction  by  an  intestinal  anastomosis. 

b.     Caecinoma. 

In  most  cases  of  carcinoma  of  the  intestine  the  disease  com- 
mences in  the  mucous  membrane,  in  which  case  the  parenchyma  of 
the  tumor  is  composed  of  cells  which  resemble  the  columnar  epithe- 
lium which  lines  the  intestinal  canal.  Carcinoma  is  found  most 
frequently  in  the  region  of  the  sigmoid  flexure,  the  caecum  and 
rectum.  A  malignant  stenosis  may  have  existed  for  months  with- 
out symptoms,  when  suddenly  symptoms  of  acute  intestinal  obstruc- 
tion are  developed,  as  in  a  case  here  related.  In  cases  of  acute 
intestinal  obstruction  in  elderly  people,  where  no  cause  for  it  can  be 
found  in  the  abdomen,  a  thorough  rectal  examination  should  never 
be  neglected. 

During  my  visit  in  Zurich  last  year  I  was  present  at  a  very 
interesting  autopsy  made  by  Klebs  upon  one  of  Kronlein's  patients. 
A  few  days  before. a  woman  forty  years  of  age  was  brought  into  the 
hospital,  presenting  well-marked  symptoms  of  intestinal  obstruction, 
which  had  lasted  for  two  weeks.  On  examination  no  cause  for  the 
obstruction  could  be  fotmd.  The  abdomen  was  very  tympanitic, 
rendering  palpation  difficult  and  unsatisfactory.  Laparotomy  was 
made,  but  as  nothing  could  be  found  and  the  small  intestines 
were  enormously  distended  throughout,  inguinal  colotomy  was  per- 
formed. The  operation  was  followed  by  decided  relief,  the  abdomen 
collapsed  and  a  large  quantity  of  faeces  was  discharged  through  the 
artificial  anus;  but  the  patient  died  of  exhaustion  the  next  day.  At 
the  post-mortem  examination  the  cause  of  the  obstruction  was  found 
20  cm.  below  the  artificial  anus,  in  the  shape  of  a  narrow,  annular, 
carcinomatous  stricture  of  the  colon.  In  his  remarks  on  the  case 
Kronlein  stated  that  he  had  observed  four  similar  cases  during  the 
time  he  had  been  in  Zurich.  It  would  be  well  in  the  future,  when  a 
similar  condition  is  suspected,  to  explore,  if  need  be,  the  upper  por- 
tion of  the  rectum  and  lower  extremity  of  the  colon  as  far  as  accessible 
by  Simon's  method,  as  in  case  the  lesion  is  recognized  and  accurately 
located,  some  of  these  cases  might  be  amenable  for  a  radical  opera- 
tion by  excision. 

Schede  ^  made  a  resection  of  the  small  intestine  for  carcinoma 

1  Verh.  der  Deutschen  Gesellschaft  f-vir  Chirnrgie,  1884. 


132  INTESTINAL  SURGERY. 

in  a  case  where  the  tumor  had  extended  to  the  abdominal  wall.  The 
intestine  was  excised  with  the  tumor  and  the  ends  united  by  circular 
suturing.  The  patient  recovered.  A  few  weeks  later  he  returned 
to  the  hospital  with  symptoms  of  complete  intestinal  obstruction. 
The  abdomen  was  again  opened  and  an  artificial  anus  was  estab- 
lished. The  patient  died  on  the  fifth  day.  The  cause  of  obstruction 
was  a  constricting  band  which  was  divided  during  the  operation. 
Schede  is  of  the  opinion  that  in  cases  of  complete  obstruction  of  the 
bowels  by  a  malignant  tumor,  excision  is  contra-indicated,  as  in  eigh 
teen  cases  of  intestinal  resection  for  malignant  disease,  of  six  cases 
in  which  the  occlusion  was  complete  all  died,  while  of  the  remaining 
twelve,  where  the  occlusion  was  only  partial,  only  three  died.  These 
statistics  should  only  induce  us  to  endeavor  to  make  a  correct 
diagnosis  before  urgent  symptoms  have  set  in,  and  to  resort  to  opera- 
tive treatment  at  a  time  when  the  general  condition  of  the  patient 
is  such  as  to  warrant  a  radical  operation,  and  the  local  conditions  at 
the  seat  of  obstruction  are  favorable  to  a  speedy  process  of  repair. 

'  If,  after  resection  of  the  lower  portion  of  the  colon,  it  is  found 
impossible  to  approximate  the  two  ends  of  the  bowel,  and  the  distal 
end  is  not  su£Sciently  accessible  to  make  an  intestinal  anastomosis 
or  lateral  implantation,  then  the  course  adopted  by  Gussenbauer  ^  in 
a  case  of  this  kind  should  be  chosen.  The  patient  was  a  man  forty- 
six  years  of  age,  who  had  suffered  for  years  from  obstinate  consti- 
pation. On  examination  a  tumor  was  discovered  the  size  of  a  hen's 
egg  in  the  left  hypogastric  region,  two  fingers'  breadth  below  a  line 
drawn  from  one  anterior  superior  spinous  process  of  the  ilium  to  the 
other.  The  tumor  could  also  be  felt  high  up  in  the  rectum  by  press- 
ing it  downwards  into  the  pelvis.  The  abdomen  was  opened  by  an 
incision  over  the  tumor  parallel  with  the  course  of  the  descending 
colon.  The  tumor  was  found  to  occupy  the  most  prominent  portion 
of  the  sigmoid  flexure,  freely  movable,  and  not  attached  to  any  of 
the  surrounding  organs.  A  few  glands  behind  the  affected  portion 
of  the  colon  were  enlarged.  Circular  resection  was  made,  including 
a  corresponding  portion  of  the  meso-colon  and  the  enlarged  lym- 
phatic glands.  On  account  of  too  great  loss  of  substance,  circular 
enterorrhaphy  could  not  be  made,  consequently  the  distal  end  was 

closed  by  invagination  and  suturing  and  dropped  into  the  abdominal 

fc_ 

'  Zur  operativen  Behandlung  der  Carcinome  des  S.  Romanam.     Prager 

Zeitschrift  f.  Heilkande,  1881. 


TUMORS.  133 

cavity,  while  the  proximal  end  was  sutured  into  the  external  wound. 
The  patient  made  a  good  recovery,  and  at  the  end  of  ten  months  the 
disease  had  not  returned. 

BulP  reports  two  cases  of  carcinoma  of  the  sigmoid  flexure 
where,  in  each  instance,  he  opened  the  abdomen  through  the  median 
line  and  stitched  the  descending  colon  into  the  wound  without  incis- 
ing it,  reserving  this  step  of  the  operation  until  adhesions  had  taken 
place.  Both  patients  recovered.  In  one  of  these  cases  he  resected 
six  inches  of  the  colon,  including  the  artificial  anus,  and  the  tumor 
twelve  months  later,  and  the  patient  again  recovered  from  the  opera- 
tion. At  the  time  the  report  was  made  the  operator  had  in  view  a 
third  operation  for  the  closure  of  the  second  artificial  anus,  which 
was  made  at  the  close  of  the  second  operation.  In  all  cases  where 
the  seat  of  ob^ruction  can  be  located  in  the  caecum  or  colon  before 
the  operation,  lateral  incision  should  be  selected,  as  it  will  afford 
better  access  to  the  seat  of  obstruction  than  median  incision. 

If  it  is  found  impossible  to  remove  the  obstruction,  one  of  two 
things  must  be  done.  If  the  bowel  below  the  obstruction  can  be 
reached,  an  intestinal  anastomosis  is  made,  or  the  ileum  is  divided 
just  above  the  ileo-csecal  valve,  the  distal  end  closed,  and  the  prox- 
imal implanted  into  the  bowel  below  the  seat  of  obstruction.  If 
resection  can  be  done  with  a  prospect  of  removing  all  the  diseased 
tissues  it  should  be  invariably  practiced  as  a  primary  radical  opera- 
tion, and  if,  on  account  of  its  extent,  circular  enterorrhaphy  cannot 
be  done,  the  distal  end  is  permanently  closed,  and  the  proximal 
stitched  into  the  wound.  If  the  distal  portion  can  be  reached  the 
continuity  of  the  intestinal  canal  is  restored  by  intestinal  anasto- 
mosis or  lateral  implantation.  If  the  seat  of  obstruction  cannot  be 
ascertained  before  the  operation  and  exploration  through  a  median 
incision  locates  it  in  the  caecum,  colon,  or  rectum,  it  may  become 
necessary  to  make  a  lateral  incision  if  a  radical  operation  is  decided 
upon,  and  when  this  appears  impossible  or  unjustifiable,  an  intestinal 
anastomosis  or  lateral  implantation  can  be  made  through  the  median 
incision.  If  on  account  of  the  location  of  the  obstruction,  either  of 
these  operations  are  also  inapplicable,  an  artificial  anus  should  be 
established  in  the  right  or  left  inguinal  region,  and  the  median 
incision  closed  and  dressed  separately. 

^  Gaillard's  Medical  Journal,  March,  1888. 


134  INTESTINAL  SURGERY. 

Y.    Dynamic  Intestinal  Obstruction  Caused  by  Suspension 

of  Peristalsis. 

A  number  of  pathological  conditions  are  known  to  produce 
symptoms  which  so  closely  resemble  intestinal  obstruction  that  the 
abdomen  has  been  repeatedly  opened  in  such  cases,  with  the  expec- 
tation of  removing  the  cause  of  the  obstruction,  but  no  occlusion 
of  any  kind  could  be  found.  These  are  the  cases  that  have  caused 
the  greatest  difficulty  in  diagnosis,  and  have  often  brought  disap- 
pointment and  reproach  upon  the  surgeon.  The  obstruction  in  these 
cases  is  not  caused  by  a  narrowing  of  the  lumen  of  the  intestine, 
but  by  suspension  of  the  dynamic  forces  which  propel  the  intestinal 
contents,  and  which  results  in  accumulation  of  fseces  and  gases  in 
the  paralyzed  portion  of  the  bowel;  which  is  followed  by  distention 
of  the  intestines,  constipation  and  obstinate  vomiting,  which  in  rare 
cases  may  become  fsecal.  Circumscribed  or  diffuse  paresis  of  the 
intestines  is  caused  either  by  an  inflammatory  affection,  such  as  peri- 
tonitis or  enteritis,  which  produces  suspension  of  muscular  contrac- 
tions in  the  same  manner  as  when  an  inflammatory  process  in  any 
other  organ  affects  directly  the  muscular  tissue,  or  the  tunics  of  the 
intestines  are  in  an  intact  condition,  but  a  paralysis  has  resulted  from 
reflex  causes. 

Pitts  ^  narrates  two  cases  in  which,  after  reduction  of  a  strangu- 
lated hernia,  he  performed  laparotomy  on  account  of  persisting 
symptoms,  and  found  no  cause  for  these  symptoms  save  that  pre- 
sented by  the  free  but  lifeless  coil  that  had  been  liberated  too  late. 

The  contents  in  a  paretic  bowel  are  liable  to  undergo  fermenta- 
tive and  putrefactive  changes,  and  the  gases  which  are  developed 
during  such  changes  accumulate  and  cause  such  an  extensive  tympan- 
ites that  the  latter  may  become  a  mechanical  cause  of  obstruction. 

I.     Tympanites. 

Cases  of  sudden  death  from  over-distention  of  the  intestines 
and  stomach  by  rapid  accumulation  of  gas  have  been  reported  by 
Dechambre,  Mercier,  L'  Pereyra,  and  others.  The  patients  were 
generally  aged  persons,  or  young  persons  during  convalesence  from 
protracted  diseases. 

1  St.  Thomas'  Hospital  Reports.     Vol.  11,  1882,  p.  75. 


TYMPANITES.  135 


« 


Gu^neau  de  Mussy/  in  a  clinical  lecture,  treats  of  the  mechani- 
cal conditions  which  cause  accumulation  of  gas  in  the  intestines. 
Where  no  mechanical  obstruction  is  present  the  gaseous  distention 
is  due  to  paralysis  of  the  sympathetic  nerves.  The  failure  of  the 
expulsion  of  the  gas  is  owing  to  the  formation  of  numerous  flexions 
from  the  over-distention,  and  later,  to  compression  of  some  parts  of 
the  intestines  by  the  distended  loops.  The  lowest  portion  of  the 
ileum  may  be  compressed  against  the  ascending  colon  so  firmly  as 
to  become  a  cause  of  complete  mechanical  obstruction.  Proof  of 
the  existence  of  such  a  mechanical  condition  is  furnished  in  cases  of 
extensive  tympanites  where  the  introduction  of  a  rectal  tube  affords 
no  relief.     In  such  cases  the  distention  increases  even  after  death. 

The  author  has  also  furnished  experimental  proof.  The  cadaver 
of  a  child  was  inflated  moderately  through  the  cesophagus,  after 
which  the  oesophagus  was  tied,  and  a  tube  was  introduced  into  the 
rectum  and  its  distal  end  immersed  under  water.  Pressure  upon 
the  abdomen  expelled  the  air  through  the  rectal  tube.  When  he 
repeated  the  experiment,  but  carried  the  distention  further,  no  air 
could  be  made  to  escape  through  the  rectal  tube  by  compressing  the 
abdomen.  On  opening  the  abdomen  with  great  care,  it  was  seen  that 
the  lower  portion  of  the  distended  ileum  was  pressed  against  the 
ascending  colon  so  firmly  as  to  completely  interrupt  the  communi- 
cation between  them.  From  these  observations  it  can  be  readily 
seen  how  the  formation  of  an  intestinal  anastomosis  would  frequently 
prove  the  means  not  only  of  relieving  the  obstruction,  but  also  of  the 
removal  of  its  cause. 

If  gas  is  present  in  the  peritoneal  cavity  as  the  result  of  putre- 
factive changes  of  the  products  of  peritoneal  inflammation,  it  presses 
the  liver  away  from  the  diaphragm,  and  the  percussion  dullness  dis- 
appears completely  when  the  patient  lies  on  his  back.  In  distention 
of  the  abdomen  from  the  presence  of  gas  in  the  intestines,  the  dia- 
phragm and  liver  are  crowded  upwards,  but  the  latter  remains  in 
contact  with  the  chest  wall,  and  the  area  of  liver  dullness  remains 
the  same,  but  is  displaced  in  an  upward  direction.  WTiere  life  is 
threatened  by  tympanitic  distention  of  the  abdomen  during  the  con- 
valescence from  acute  diseases,  the  symptoms  appear  very  rapidly 
and  death  results  from  mechanical  compression  of  important  organs. 

^Des  conditions  Mecaniqnes  de  la  tympanite.     Gaz.  hebd.,  No.  31,  1867. 


136     '  INTESTINAL   SURGERY. 

Puncture  of  the  distended  intestines  followed  by  aspiration,  if  need 
be,  repeated  at  short  intervals,  is  positively  indicated  in  such  ca^es. 
There  can  be  no  doubt  that  in  many  cases  of  peritonitis  attended  by 
diffuse  and  excessive  tympanites  the  symptoms  which  point  to  intes- 
tinal obstruction  are  due  to  the  same  causes,  viz. :  flexions  and  com- 
pression, and  such  cases  would  also  be  greatly  benefited  and  some- 
times cured  by  the  same  treatment. 

2.     Peritonitis. 

Peritonitis  may  lead  to  symptoms  resembling  intestinal  occlu- 
sion in  different  ways,  according  to  the  extent  and  type  of  the  disease. 
In  extensive  plastic  peritonitis  the  immobilization  of  a  considerable 
portion  of  the  small  intestines  may  give  rise  to  persistent  vomiting, 
and  absolute  constipation.  Again,  as  we  have  just  seen,  arrest  of  the 
fsecal  circulation  may  be  caused  by  the  tympanites  alone,  while  per- 
forative peritonitis  is  attended  by  a  local  and  general  shock,  which 
causes  intestinal  paresis  through  the  sympathetic  nerves.  Heusner^ 
has  observed  that  perforative  peritonitis  gives  rise  to  disturbances 
simulating  intestinal  obstruction,  by  arresting  intestinal  movements. 
He  narrates  the  histories  of  two  cases  of  this  kind  where  the  symp- 
toms of  intestinal  obstruction  were  so  prominent  that  laparotomy 
was  performed.  In  both  cases  perforative  peritonitis,  but  no  occlu- 
sion, was  found. 

Henrot,^  in  his  classical  monograph  on  pseudo-strangulation, 
describes  a  number  of  cases  of  perforation  of  the  gall-bladder  and  the 
processus  vermiformis,  where  the  symptoms  during  life  had  pointed 
so  strongly  to  the  existence  of  intestinal  obstruction  that  a  wrong 
diagnosis  was  made  by  able  clinicians.  He  also  calls  attention  to 
those  cases  of  paralytic  obstruction  which  are  often  observed  after 
herniotomy,  and  in  cases  of  strangulation  of  the  appendix  vermi- 
formis and  testicle.  The  intestinal  paresis,  where  it  is  not  the 
result  of  inflammation,  must  be  looked  upon  as  a  reflex  symptom. 

Physical  signs  and  symptoms  are  sometimes  utterly  inadequate 
to  distinguish  between  acute  intestinal  obstruction  and  diffuse  peri- 
tonitis. In  differentiating  between  these  two  conditions,  it  must  be 
remembered  that  in  the  absence  of  a  tumor,  absolute  constipation  and 
fsecal  vomiting  are  the  most  characteristic  symptoms  of  obstruction, 

1  Deutsche  Med.  Wochenschrift,  1877. 

2  Des  Pseudo-6tranglements,  etc.,  Th^se,  Paris,  I8660 


CATARRHAL  AND    ULCERATIVE  ENTERITIS.  137 

and  that  in  peritonitis  the  pain  is  severe  and  continuous,  with  difPuse 
tenderness,  tympanites,  and  absence  of  visible  intestinal  coils.  In 
mechanical  obstruction  of  the  bowels  the  temperature  as  a  rule  is  not 
above  normal  unless  complications  have  set  in,  while  in  peritonitis 
a  rise  in  temperature  is  the  rule,  although  in  some  of  the  gravest 
cases  it  is  sub-normal.  Many  cases  of  supposed  recovery  from 
intestinal  obstruction  without  operation  undoubtedly  were  cases  of 
dynamic  obstruction,  and  the  recovery  was  either  entirely  spontane- 
ous, or  facilitated  by  means  which  assisted  in  the  restoration  of 
peristaltic  action.  In  1851  a  patient  was  admitted  into  Dupuytren's 
ward  with  well-marked  symptoms  of  acute  intestinal  obstruction. 
This  eminent  surgeon  gave  it  as  his  opinion  that  without  an  opera- 
tion a  fatal  termination  was  inevitable,  but  the  patient  objected  to 
the  operation  and  was  transferred  to  another  ward,  where  he  re- 
covered in  three  days  under  the  use  of  simple  cathartics.  Numerous 
similar  cases  could  be  cited  in  illustration  of  the  difficulty  of  differ- 
entiating in  all  cases  between  mechanical  occlusion  and  dynamic 
obstruction. 

3.    Catarrhal  and  Ulcerative  Enteritis. 

For  some  reasons  which  at  present  it  is  difficult  to  explain, 
simple  catarrhal  enteritis  and  circumscribed  ulcerations  of  the  small 
intestines  have  occasionally  been  the  cause  of  rapid  accumulations 
of  gas,  followed  by  symptoms  of  intestinal  obstruction.  Mercier' 
has  recorded  a  case  where  a  patient  died  after  a  brief  illness,  during 
which  all  symptoms  pointed  to  the  existence  of  intestinal  obstruction, 
including  complete  constipation  and  fsecal  vomiting.  The  necropsy 
showed  no  stenosis  or  any  other  form  of  mechanical  obstruction,  but 
several  large  ulcers  in  the  middle  of  the  ileum. 

Hosier^  reports  a  case  of  acute  intestinal  obstruction  which 
followed  a  catarrhal  enteritis,  where  on  post-mortem  no  primary 
mechanical  obstruction  could  be  found.  The  small  intestines  were 
so  enormously  distended  that  they  filled  the  entire  abdominal  cavity, 
compressing  the  ascending  colon  so  firmly  as  to  render  it  completely 
impermeable;  the  transverse  colon  was  also  compressed,  but  to  a 
lesser  extent. 

^  Note  sur  deux  cas  d  ileus.     Gazette  M^d.  de  Paris,  1867,  p.  151. 
2  Ueber  den  Ileus.     Archiv  der  Heilkunde,  No.  2,  1864. 


138  INTESTINAL  SURGERY. 

Zimmermann  ^  described  a  case  of  acute  intestinal  obstruction, 
where  during  life  the  collapse  came  on  so  rapidly  as  to  resemble 
cholera.  The  bowels  remained  completely  constipated,  and  the 
vomiting  was  so  severe  and  persistent  that  on  the  seventh  day  it 
became  stercoraceous.  The  patient  lived  six  weeks.  At  the  necropsy 
the  small  intestines  were  found  enormously  distended  and  their 
walls  very  much  attenuated;  the  colon  was  also  distended.  In  the 
ileum  a  number  of  small  ulcers  were  found,  which  had  destroyed  the 
entire  thickness  of  the  mucous  membrane.  In  a  case  of  this  kind 
Obalinski  made  a  laparotomy,  and  as  he  found  the  external  surface 
of  the  lower  portion  of  the  ileum  only  congested,  but  no  mechanical 
obstruction,  he  closed  the  external  incision  and  the  patient  recovered. 
He  believed  that  in  this  case  there  were  typhoid  ulcers  which  caused 
a  functional  stricture  of  the  gut  and  the  symptoms  which  induced 
him  to  open  the  abdomen. 

4.    Exventration. 

At  a  recent  meeting  of  the  Berlin  Obstetrical  Society,  Olshausen 
reported  several  cases  of  laparatomy,  in  which  more  or  less  exven- 
tration became  unavoidable  during  the  operation.  A  few  days 
after  the  operation  the  patients  presented  all  the  appearances  of  an 
attack  of  acute  intestinal  obstruction,  and  death  followed  five  to  ten 
days  after  the  operation.  Olshausen  explained  the  symptoms  during 
life  and  the  fatal  termination,  by  assuming  the  existence  of  intestinal 
paralysis,  distention  of  the  bowel  and  absorption  of  toxic  agents  from 
the  intestinal  canal.  During  the  exventration  the  intestines  became 
engorged  by  venous  hypersemia,  which  in  turn  again  was  followed  by 
exudation  into  the  tissues  of  the  bowel. 

Sebileau^  re-opened  the  abdomen  in  two  cases  of  acute  intestinal 
obstruction  after  laparotomy,  and  no  mechanical  occlusion  or 
exudation  of  any  kind,  but  enormous  meteorism  was  found.  He 
attributes  this  condition  to  intestinal  paresis  and  rapid  accumulation 
of  gas.  The  prophylactic  treatment  of  such  cases  is  more  important 
than  the  curative.  The  administration  of  a  brisk  cathartic  on  the 
second  or  third  day  after  the  operation,  will  usually  prevent  tympan- 

^  Ein  Beitrag  zur  Lehre  vom  dynamischen  Ileus.  Canstatt's  Jahresbericht, 
B.  3,  1860,  p.  245 

2  De  quelques  accidents  intestinaax  snrvenant  aprfes  les  operations 
abdominales.     Annal.  de  Gynecologie,  T.  XXV,  p.  118. 


EXVENTRATION.  139 

itic  distention  of  the  abdomen  by  stimulating  the  paretic  walls  to 
active  muscular  contractions,  and  by  removing  the  intestinal  contents, 
the  Bource  of  putrefactive  changes.  This  treatment  should  never  be 
postponed  until  the  paralysis  has  been  aggravated  by  over- disten- 
tion, but  should  be  resorted  to  either  before,  or  upon  the  first 
appearance  of  intestinal  distention. 

(  Uniform  compression  of  the  abdomen  with  strips  of  adhesive 
plaster  and  bandage  applied  over  the  antiseptic  absorbent  dressing 
immediately  after  the  operation  should  be  kept  up  until  all  danger 
from  the  occurrence  of  tympanites  has  passed.!  When  the  distention 
has  become  so  great  as  to  threaten  life,  the  treatment  should  consist 
of  the  employment  of  such  prompt  mechanical  measures  as  will 
diminish  the  intra-abdominal  pressure.  As  the  stomach  may  also  be 
dilated,  its  contents  should  be  removed  through  a  flexible  stomach 
tube,  followed  by  an  irrigation  with  a  harmless  antiseptic  solution. 
Tubage  of  the  colon  followed  by  a  turpentine  enema  is  used  for  the 
same  purpose.  If  these  measures  fail  in  relieving  the  distention,  a 
prompt  resort  to  intestinal  puncture  with  a  fine  hollow  needle  becomes 
imperative.  This  surgical  resource  may  be  repeated  as  often  as  it 
may  become  necessary  to  avert  danger  from  an  increasing  intra- 
abdominal wressure. 


AN    EXPEEIMENTAL    CONTKIBUTION     TO     INTES- 
TINAL SUEGEEY  WITH  SPECIAL  REFER- 
ENCE    TO     THE     TREATMENT     OF 
INTESTINAL  OBSTRUCTION.^ 


The  most  important,  and,  at  the  same  time,  the  most  popular 
topic  for  discussion  among  surgeons  of  the  present  day  is  intestinal 
surgery.  The  current  medical  literature  is  teeming  with  reports  of 
cases,  and  at  the  meetings  of  almost  every  medical  and  surgical  soci- 
ety, large  or  small,  this  subject  comes  up  for  discussion  and  occupies 
a  liberal  space  and  conspicuous  place  in  their  printed  transactions. 
The  unusual  activity  which  has  been  manifested  in  all  parts  of  the 
civilized  world  in  the  development  of  this,  one  of  the  most  modern 
and  aggressive  departments  of  abdominal  surgery,  is  sufficient 
evidence  that  the  subject  is  comparatively  new,  and  as  yet  imper- 
fectly understood.  A  study  of  the  literature  of  intestinal  surgery 
must  convince  every  unprejudiced  mind  that  here,  as  in  many  other 
difficult  problems  in  surgery,  the  positive  knowledge  which  we  have 
acquired  rests  almost  exclusively  on  the  results  obtained  by  experi- 
mental research.  Gunshot  wounds  of  the  abdominal  cavity  have 
been  made  the  object  of  careful  and  patient  experimentation  by  a 
number  of  enthusiastic  surgeons,  and  the  results  obtained  have  laid 
the  foundation  for  a  rational  method  of  treatment  of  these  injuries, 
which  has  been  eagerly  accepted  by  all  modern  aggressive  and  pro- 
gressive surgeons.  The  practical  results  which  have  been  obtained 
thus  far  in  the  hands  of  a  number  of  surgeons  have  been  the  means 
of  saving  a  number  of  lives,  which  by  the  old  conservative  method  of 
treatment  would  have  been  doomed  to  inevitable  death  from  haemor- 
rhage or  septic  peritonitis.  The  numerous  valuable  practical  sugges- 
tions for  treatment  of  gunshot  injuries  of  the  intestines  are  the 
direct   outcome   of  experiments  on  animals,   and  this,   as  well   as 

1  Read  in  the  Surgical  Section  of  the  Ninth  International  Medical  Congress, 
Washington,  September  5,  1887. 

141 


142  INTESTINAL  SURGERY. 

the  remarkable  recoveries  following  gunshot  wounds  of  the  abdomen 
treated  by  laparotomy,  have  so  firmly  convinced  the  profession  of 
the  necessity  of  resorting  to  operative  measures  in  such  cases,  that 
few  surgeons  could  be  found  at  the  present  day  who  would  be  willing 
to  trust  to  conservative  treatment  any  case  where  positive,  or  only 
probable,  evidences  pointed  towards  the  existence  of  a  visceral  injury 
of  any  portion  of  the  intestine. 

While  a  decided  advance  has  been  made  in  the  treatment  of 
injuries  of  the  intestinal  tract,  the  operative  treatment  of  intestinal 
obstruction  still  constitutes  one  of  the  darkest  and  most  unsatisfactory 
chapters  in  the  wide  domain  of  intestinal  surgery.  The  obscurity 
and  uncertainty  which  cling  to  this  subject  are  due  to  the  difficulties 
which  often  surround  an  accurate  diagnosis.  At  the  same  time  we 
have  every  reason  to  believe  that  the  appalling  mortality  which  has 
so  far  attended  the  surgical  treatment  of  intestinal  obstruction  is 
mainly  due  to  late  operations,  and  not  infrequently  to  a  faulty 
technique  in  the  removal  of  the  cause  of  the  obstruction,  and  in 
the  restoration  of  the  continuity  of  the  intestinal  canal.  An  accurate 
anatomical  or  pathological  diagnosis  in  such  cases  during  life  is  often 
difficult,  if  not  impossible,  and  when,  as  a  dernier  ressort,  laparot- 
omy is  performed,  and  the  surgeon  is  confronted  by  an  unexpected 
condition  of  things,  he  is  often  in  doubt  as  to  what  course  to  pursue, 
and  frequently  ends  the  operation  by  establishing  an  artificial  anus. 
No  one  who  has  been  forced  to  resort  to  this  measure  has  left  his 
patient  with  a  feeling  of  satisfaction,  as  he  must  have  been  sadly 
impressed  with  the  fact,  that,  at  best,  he  has  only  been  instrumental 
in  relieving  the  urgent  symptoms  of  the  obstruction,  while  he  has 
failed  to  remove  its  cause,  and  consequently  also  in  restoring  the 
continuity  of  the  intestinal  canal.  A  patient  with  an  artificial  anus 
is  indeed  an  object  of  commiseration,  as  experience  has  sufficiently 
demonstrated  how  difficult  it  is  in  many  instances  to  close  the  abnor- 
mal outlet,  even  after  the  cause  of  obstruction  is  subsequently 
removed  or  corrected  spontaneously,  withoiit  exposing  him  a  second 
time  to  the  risks  of  life  incident  to  another  abdominal  sectidn.  If 
the  causes  which  have  led  to  the  obstruction  are  of  a  permanent 
character,  all  attempts  at  closing  the  fistulous  opening  will,  of  course, 
prove  worse  than  useless,  and  the  patient  is  condemned  to  suffer  from 
this  loathsome  condition  the  balance  of  his  or  her  lifetime,  without  a 
hope  of  ultimate  relief.     I  believe  I  can  safely  make  the  statement 


TREATMENT   OF  INTESTINAL    OBSTRUCTION.  143 

without  fear  of  contradiction  that  most  of  these  unfortunate  patients 
would  prefer  death  itself  to  such  a  life  of  misery.  The  ideal  of  an 
operation  for  intestinal  obstruction  embraces  the  fulfillment  of  two 
principal  indications: 

1.  The  removal  or  rendering  harmless  of  the  cause  of  obstruc- 
tion. 

2.  The  immediate  restoration  of  the  continuity  of  the  intestinal 
canal. 

To  meet  the  first  indication  the  cause  of  obstruction  must  be 
found,  its  nature  determined,  and  whenever  advisable  or  practicable, 
it  is  removed,  a  step  in  the  operation  which  may  be  very  easy,  or 
may  demand  a  most  formidable  and  serious  undertaking,  more 
especially  in  cases  where  the  pathological  conditions  which  have 
given  rise  to  the  obstruction  are  of  such  a  nature  as  to  constitute  in 
themselves  an  imminent  or  remote  source  of  danger,  as,  for  instance, 
malignant  disease  or  gangrene  of  the  bowel  from  constriction.  In 
all  cases  of  inoperable  conditions  the  cause  of  obstruction  is  rendered 
harmless  as  far  as  obstruction  is  concerned  by  establishing  an 
anastomosis  between  the  bowel  above  and  below  the  obstruction  by 
an  operation  which  will  be  described  further  on. 

Immediate  restoration  of  the  continuity  of  the  intestinal  canal 
should  be  secured  in  the  operative  treatment  of  all  cases  of  intesti- 
nal obstruction,  with  the  exception  of  inoperable  cases  of  carcinoma 
of  the  rectum,  but  is  most  urgently  indicated  in  cases  of  obstruction 
in  the  upper  portion  of  the  small  intestines  and  the  colon,  as  the 
formation  of  an  artificial  anus  in  the  former  locality  would  prove 
a  direct  source  of  danger  from  marasmus,  by  excluding  too  large  a 
surface  for  intestinal  digestion  and  absorption,  while  in  the  latter 
situation  the  cure  of  a  faecal  fistula  only  too  often  proves  an  oppro- 
brium of  surgery.  A  careful  perusal  of  the  literature  on  the 
treatment  of  intestinal  obstruction  proves  only  too  plainly  the  im- 
perfection of  this  branch  of  surgery.  The  rules  laid  down  in  our 
text-books  are  often  given  with  so  much  hesitation  that  it  becomes 
impossible  to  apply  them  in  practice.  Opinions  are  so  widely  at 
variance  that  every  surgeon  finally  acts  upon  the  impulse  of  the 
moment  and  adopts  a  method  which  he  deems  appropriate  for  his 
case.  It  can  be  said  that  no  uniformity  of  action  exists,  consequently 
the  statistics  which  have  been  produced  so  far  are  of  but  little  value 
from  a  practical   standpoint.     A  rational   and  successful  surgical 


144  INTESTINAL   SURGERY. 

treatment  of  intestinal  obstruction,  like  other  abdominal  operations, 
can  only  be  established  upon  a  basis  founded  upon  the  results 
obtained  by  experimental  investigation.  In  view  of  this  fact  it  is 
astonishing  that  so  little  has  been  accomplished  in  this  direction.  I 
am  convinced  that  accurate  work  of  this  kind  will  render  essential 
information  in  the  diagnosis  of  the  obscure  causes  of  obstruction, 
and  will  point  out  more  clearly  the  indications  for  operative  inter- 
ference, while  improved  methods  of  operation  will  have  to  be  studied 
exclusively  in  this  manner. 

During  the  last  eighteen  months  I  have  made  one  hundred  and 
fifty  operations  on  animals  for  the  purpose  of  studying  the  effects 
of  the  principal  varieties  of  intestinal  obstruction,  which  were  pro- 
duced artificially ;  at  the  same  time  I  have  attempted  to  establish 
a  number  of  new  operations  for  the  relief  of  certain  forms  of  intes- 
tinal obstruction  where  it  is  impossible  or  inadvisable  to  remove  the 
local  conditions  which  gave  rise  to  the  obstruction.  One  of  the 
greatest  dangers  in  all  operations  for  intestinal  obstruction  is  the 
length  of  time  required  to  perform  the  ordinary  operations ;  hence 
it  has  been  my  object  to  simplify  the  operations,  and  thus  by  short- 
ening the  time  diminish  the  danger  from  shock.  All  patients 
requiring  an  operation  for  intestinal  obstruction  are  invariably  in 
a  condition  not  well  adapted  for  prolonged  operations,  which  neces- 
sitate the  opening  of  the  peritoneal  cavity  and  exposure  of  its 
contents  to  the  cooling  influences  of  the  atmospheric  air.  An  opera- 
tion which  can  be  completed  in  twenty  minutes  must  certainly  prove 
less  disastrous  to  the  patient  than  one  requiring  from  one  to  two 
hours.  A  prolonged  operation  on  the  intestines  is  attended  by  two 
great  risks  :  1.  Immediate,  due  to  shock.  2.  Remote,  prolonged 
exposure  to  infection.  Both  of  these  dangers  are  diminished  in 
proportion  to  the  shortening  of  the  time  consumed  in  the  operation, 
which  is  made  possible  by  resorting  to  simpler  measures,  provided 
they  are  equally  safe  and  efiicient. 

General  Remarks  on  Experiments. 

With  few  exceptions  the  experiments  detailed  in  this  paper 
were  made  at  the  Milwaukee  County  Hospital,  located  at  Wauwatosa, 
six  miles  from  Milwaukee;  and  here  I  desire  to  return  my  thanks 
to  Dr.  M.  E.  Connel,  superintendent  of  the  hospital,  and  his 
assistants,   as   well   as   to  Dr.  William  Mackie,  of  Milwaukee,  for 


REMARKS   ON  EXPERIMENTS.  145 

valuable  services  rendered  in  my  experimental  work.  As  the  main 
object  of  these  experiments  was  not  to  show  favorable  statistics,  but 
more  for  the  purpose  of  studying  the  efPect  of  different  forms  of 
intestinal  obstruction  and  to  establish  new  principles  of  treatment, 
the  animals  were  not  submitted  to  any  special  treatment  before  or 
after  the  operation;  the  diet  was  not  restricted  and  no  internal 
medicines  were  given.  I  pursued  this  course  in  order  to  bring  the 
intestinal  canal  in  the  most  unfavorable  conditions  for  operative 
interference,  so  as  to  expose  the  operations  to  the  severest  test. 
Ether  was  used  exclusively  as  an  ansesthetic.  The  abdomen  was 
shaved,  thoroughly  washed  with  soap  and  warm  water,  and  disin- 
fected with  a  1-1000  solution  of  corrosive  sublimate  or  a  two  and  a 
half  per  cent,  solution  of  carbolic  acid.  For  the  sponges  the  same 
solution  of  carbolic  acid  or  a  weaker  solution  of  corrosive  sublimate 
was  used.  The  abdomen  was  covered  by  several  layers  of  aseptic 
gauze,  with  a  slit  in  the  centre. 

Whenever  division  or  incision  of  the  bowel  was  made,  fsecal 
extravasation  was  guarded  against  by  compressing  the  bowel  on  each 
side  by  compressors  made  for  this  special  purpose,  or  by  constriction 
with  an  elastic  rubber  band.  Experience  showed  that  the  latter 
method  was  preferable,  as  it  proved  less  injurious  to  the  tissues  of 
the  bowel,  and  aflPorded  greater  security  against  extravasation,  while 
at  the  same  time  it  proved  less  disastrous  to  the  circulation  between 
the  points  of  compression.  The  rubber  bands  for  this  purpose  should 
be  about  an  eighth  of  an  inch  in  width,  rendered  properly  aseptic  by 
prolonged  immersion  in  a  five  per  cent,  solution  of  carbolic  acid,  and 
can  be  readily  applied  by  perforating  the  mesentery  with  an  ordinary 
haemostatic  forceps  at  a  point  not  supplied  with  visible  blood  vessels, 
and  tied  in  a  loop  with  sufficient  firmness  to  obstruct  the  lumen  of 
the  bowel.  Elastic  constriction  practiced  in  this  manner  prevents  all 
possibility  of  extravasation,  and  does  not  interfere  with  the  free 
manipulations  of  the  operator,  as  is  the  case  with  clamps  or  the 
hands  of  an  assistant,  while  the  degree  of  compression  that  is 
necessary  exerts  no  injurious  effects  on  the  vessels  and  tissues  at 
the  seat  of  constriction.  Drainage  was  never  resorted  to,  and  the 
abdominal  wound  was  always  closed  by  deep  interrupted  sutures 
including  the  peritoneum.  In  all  cases  where  partial  or  complete 
exventration  was  made  necessary,  the  bowels  were  kept  covered  with 
warm  gauze  compresses.     In  all  cases  where  complete  exventration 

10 


146  INTESTINAL  SURGERY. 

became  necessary,  and  where  the  bowels  remained  out  of  the 
abdomen  for  half  an  hour  or  more,  a  certain  degree  of  shock  was 
always  noticed,  and  a  number  of  animals  died  within  a  few  hours 
after  the  operation,  death  being  referable  directly  to  this  cause.  For 
an  external  dressing  we  used  iodoform  ointment  applied  directly 
over  the  wound,  and  a  compress  of  cotton,  retained  by  a  bandage, 
and  a  jacket  made  of  coarse  cloth.  As  a  rule  the  sutures  were 
removed  at  the  end  of  six  days,  when  the  wound  was  usually  found 
healed  by  primary  union. 

I.    Artificial  Intestinal  Obstruction. 

In  imitation  of  the  more  common  forms  of  intestinal  obstruction 
in  the  human  subject,  due  to  congenital  malformation  or  pathologi- 
cal conditions,  the  following  kinds  of  obstruction  were  produced  on 
animals:  (1)  stenosis,  (2)  flexion,  (3)  volvulus,  (4)  invagination.  It 
is  a  noteworthy  fact  that  even  in  cases  where  the  obstruction  was 
complete  from  the  beginning,  vomiting  was  moderate,  and  in  some 
instances  entirely  absent.  As  vomiting  constitutes  one  of  the  earliest 
and  most  conspicuous  and  persistent  symptoms  in  most  cases  of 
intestinal  obstruction  in  man,  we  can  only  explain  its  lesser  intensity 
or  complete  absence  in  animals  from  the  circumstance  that  animals 
suffering  from  this  condition,  as  a  rale,  refuse  all  food  and  drink. 
As  a  rule,  the  tympanitis  was  also  less  marked  than  in  the  human 
subject. 

I.    Stenosis. 

Circular  narrowing  of  the  lumen  of  the  bowel  was  produced  by 
excision  of  a  semi-lunar  piece  of  the  intestinal  wall  and  double 
suturing  of  the  wound  in  a  direction  parallel  to  the  intestine ;  and  by 
circular  constriction  with  bands  of  aseptic  gauze. 

a.    Partial  Enterectomy. 

Experiment  1.  Dog,  weight  thirty-nine  pounds.  A  semi-lunar  portion 
embracing  half  the  circumference  of  the  bowel  removed  from  the  convex 
surface,  two  inches  above  the  ileo-csecal  valve.  Wound  closed  in  a  longitudinal 
direction  by  Czerny-Lembert  suture.  The  first  two  weeks  the  discharges 
from  the  bowels  were  fluid  and  dark  in  color,  subsequently  normal  in  color  and 
consistence.  Animal  killed  thirty-six  days  after  operation.  Body  well  nour- 
ished; abdominal  wound  indicated  by  a  firm  linear  cicatrix.  Omentum 
adherent  at  point  of  operation;  lumen  of  bowel  at  point  of  operation  reduced 
one-half  in  size;  lumen  of  bowel  above  and  below  the  contraction  equal  in  size, 
showing  that  the  stenosis  had  not  furnished  an  obstacle  to  the  passage  of 


STENOSIS.  147 

intestinal  contents.    A  few  of  the  satures  remained  attached,  their  free  ends 
floating  in  the  bowel. 

Experiment  2.  Large,  full-grown  cat.  The  same  operation  was  performed 
on  the  concave  side  of  the  bowel  about  the  middle  of  the  ileum,  a  semi-lunar 
piece  of  the  wall  of  the  intestine  with  the  corresponding  mesentery  being 
removed  and  the  wound  closed  in  a  similar  manner,  which  diminished  the 
diameter  of  the  lumen  of  the  bowel  to  about  one-eighth  of  an  inch.  It  was 
noticed  during  the  operation  that  the  convex  surface  of  the  bowel  over  an 
area  corresponding  to  the  partial  excision  presented  a  cyanosed  appearance. 
The  animal  died  on  the  fourth  day  after  operation,  and  the  whole  segment  of 
the  sutured  bowel  was  found  gangrenous,  but  no  fluid  in  the  abdominal 
cavity. 

Experiment  3.  Large,  adult  cat.  In  this  case  a  segment  of  the  ileum  was 
emptied  of  its  contents,  and  before  cutting  away  a  semi-lunar  piece  from  the 
convex  surface,  a  back-stitch,  continuous  suture  was  applied  on  the  inner 
margin  of  the  proposed  line  of  incision,  which  left  about  one-third  of 
the  lumen  of  the  bowel.  After  excision  of  the  semi-lunar  piece  the  margins 
of  the  cut  surface  were  turned  inwards  and  covered  with  serous  surface  by  a 
continuous  catgut  suture.  Several  smaU  passages  occurred  after  the  operation, 
but  the  animal  died  on  the  fourth  day  with  symptoms  of  intestinal  obstruction. 
The  visceral  wound  was  found  healed,  but  the  lumen  had  become  so  narrow 
from  the  inflammatory  swelling  of  the  tunics  of  the  bowel  that  it  was  entirely 
inadequate  for  the  passage  of  intestinal  contents,  and  as  a  result  of  this 
obstruction  the  bowel  had  become  considerably  dilated  above  the  point 
of  operation. 

Kemaeks. — These  experiments  illustrate  conclusively  that  in 
wounds  of  the  convex  side  of  the  intestine,  where  from  the  nature  of 
the  injury  transverse  suturing  is  impossible,  longitudinal  approxima- 
tion and  suturing  can  be  safely  done,  provided  at  least  one-half  of 
the  lumen  of  the  bowel  can  be  preserved.  If  the  stenosis  is  carried 
beyond  this  point  there  is  great  danger  that  the  inflammatory  swell- 
ing following  the  operation  will  still  further  narrow  the  tube  and 
lead  to  the  most  serious  consequences  due  to  intestinal  obstruction, 
and  place  the  visceral  wound  in  the  most  unfavorable  condition  for 
the  healing  process. 

Experiment  No.  2  shows  the  great  danger  of  interference  with 
the  blood  supply  from  the  mesentery  in  longitudinal  suturing  of 
wounds  on  the  concave  side  of  the  bowel,  as  such  a  procedure  is 
invariably  followed  by  gangrene  of  the  corresponding  segment  of 
bowel  on  the  convex  side. 

b.    Circular  Oonstriction. 

The  following  experiments  were  made  to  study  the  efPect  of 
circular  constriction  upon  the  circulation  of  the  isolated  constricted 


148  INTESTINAL  SURGERY. 

loop  of  bowel.  In  all  cases  where  the  constriction  was  made  with  a' 
gauze  band,  this  was  tied  with  the  same  degree  of  firmness,  so  as  to 
determine  whether  the  same  degree  of  strangulation  would  produce 
identical  results. 

Experiment  4.  Adult  cat.  A  loop  of  bowel  about  the  middle  of  the 
ileum,  six  inches  in  length,  was  tied  with  a  band  of  aseptic  gauze  with  suffi- 
cient firmness  to  cause  slight  congestion,  but  without  interfering  with  a  free 
arterial  supply,  as  the  arteries  in  the  ligated  portion  continued  to  pulsate 
freely.  The  day  after  operation  a  few  small  faecal  discharges  stained  with 
blood.  The  cat  died  forty-eight  hours  after  the  operation.  No  rise  in  temper- 
ature was  observed,  and  death  was  evidently  caused  by  coUapse  from  perfora- 
tion. The  loop  of  bowel  showed  gangrene  on  convex  side  equidistant  from 
the  point  of  strangulation,  and  a  small  perforation  which  had  given  rise  to 
dififuse  septic  peritonitis.  The  whole  visceral  and  parietal  peritoneum  was 
uniformly  affected  and  the  peritoneal  cavity  contained  a  considerable  quan- 
tity of  sero-sanguinolent  fluid. 

Experiment  5.  Large,  adult  cat.  A  loop  of  the  ileum  of  the  same  length 
was  tied  in  a  similar  manner  and  with  same  degree  of  firmness.  The  animal 
absolutely  refused  food  until  the  eighth  day.  Rise  in  temperature  second  and 
third  day.  Only  one  fsecal  discharge  on  the  second  day.  Killed  eight  days 
after  operation.  Abdominal  wound  completely  united;  no  peritonitis.  Four 
inches  of  bowel  below  the  point  of  constriction  showed  that  partial  reduc- 
tion had  taken  place.  The  gauze  band  was  found  completely  covered  with 
adherent  omentum,  and  a  thick  layer  of  plastic  lymph  which  formed  a  com- 
plete bridge  connecting  the  intestine  above  and  below  the  ligature.  The 
ligated  portion  showed  no  evidence  of  defective  circulation,  and  no  ulceration 
underneath  the  ligature.  The  obstruction  was  complete,  as  no  fluid  could  be 
forced  through  the  bowel,  and  in  proof  that  the  same  condition  existed  during 
life,  it  was  found  that  the  bowel  above  the  constriction  was  considerably 
dilated,  while  below  the  strangulation  it  was  empty  and  contracted. 

Experiment  6.  Large,  Maltese  cat.  A  loop  of  the  ileum,  six  inches  in 
length,  tied  in  a  similar  manner.  On  the  third  day  faeces  stained  with  blood. 
On  the  same  day  the  temperature,  which  had  remained  nearly  normal  until 
this  time,  rose  to  105°  F.,  and  on  the  following  day  the  animal  died,  having 
manifested  symptoms  of  perforative  peritonitis  for  twenty-four  hours. 
Abdominal  wound  united;  recent  diffuse  peritonitis.  The  abdominal  cavity 
contained  several  ounces  of  sero-purulent  fluid.  Bowel  above  constriction 
distended  with  fluid  contents,  below  the  obstruction  empty  and  slightly  con- 
tracted. The  greater  portion  of  strangulated  loop  was  found  gangrenous  and 
adherent  to  adjacent  loops  of  bowel.  Perforation  had  taken  place  in  the 
middle  of  the  loop  on  the  convex  surface,  showing  that  gangrene  had  taken 
place  first  at  this  point  and  had  extended  from  here  towards  the  ligature. 

Experiment  7.  Adult  dog,  weight  twenty-six  pounds.  In  this  case  an 
opening  was  made  in  the  mesentery  through  which  a  loop  of  the  small  intes- 
tine, six  inches  in  length,  was  pushed.     With  sutures  this  opening  was  made 


FLEXION.  149 

sufficiently  small  so  that  its  margins  produced  slight  strangulation.  The  dog 
remained  perfectly  well  after  the  operation,  and  was  killed  on  the  twenty- 
second  day.  Abdominal  wound  completely  healed.  No  signs  of  peritonitis. 
On  searching  for  the  seat  of  obstruction  it  was  found  that  spontaneous  reduc- 
tion had  taken  place,  the  site  of  perforation  in  the  mesentery  being  indicated 
by  a  recent  cicatrix. 

Remarks. — The  post-mortem  appearances  in  these  cases  demon- 
strate clearly  that  the  gangrene  was  not  produced  by  the  primary 
mechanical  strangulation,  but  that  it  depended  upon  consecutive 
pathological  changes  in  the  loop  or  its  vessels.  In  experiment  No.  5 
the  primary  strangulation  was  fully  as  great  as  in  the  preceding 
experiment,  and  yet  gangrene  did  not  take  place,  and  we  have  posi- 
tive proof  that  vascular  engorgement  in  the  ligated  portion  was  less 
intense  from  the  fact  that  partial  reduction  took  place.  In  all  cases 
where  gangrene  resulted,  it  must  not  have  been  from  deficient  arte- 
rial blood  supply,  but  from  an  obstruction  to  the  return  of  blood 
through  the  veins.  If  defective  arterial  blood  supply  had  been 
the  immediate  cause  of  the  gangrene,  we  would  have  found  more 
constantly  gangrene  of  the  entire  loop,  while  every  specimen  illus- 
trated that  gangrene  always  commenced  at  a  point  where  the  return 
of  venous  blood  met  with  the  greatest  resistance,  viz.,  on  the  convex 
surface  in  the  middle  portion  of  the  loop.  As  in  cases  of  hernia, 
or  in  any  other  form  of-  intestinal  strangulation,  where  a  firm  con- 
stricting band  surrounds  the  loop  of  bowel,  the  danger  of  complete 
strangulation  is  increased  if  by  the  peristaltic  action  additional 
portions  of  the  intestine  are  forced  through  the  ring ;  and  the  imme- 
diate cause  of  the  gangrene  is  always  referable  to  obstruction  to  the 
return  of  venous  blood,  which  leads  rapidly  to  oedema,  complete 
stasis,  and  moist  gangrene  in  that  portion  where  the  venous  circula- 
tion is  most  seriously  impaired.  Violent  peristalsis  under  such 
circumstances  always  aggravates  the  existing  conditions,  and  is  often 
the  precursor  of  symptoms  of  complete  strangulation.  In  such 
cases  opiates  act  favorably  by  arresting  peristaltic  action,  and  in  so 
doing  may  avert  gangrene  by  preventing  the  causes  which  otherwise 
would  have  led  to  complete  venous  stasis. 

2.    Flexion. 

As  many  instances  are  on  record  where  flexion  of  the  bowel 
constituted  the  cause  of  intestinal  obstruction,  this  condition  was 
artificially  produced  in  animals  either  by  making  a  partial  enterec- 


150  INTESTINAL  SURGERY. 

tomy  by  removing  a  wedge-shaped  piece  from  one  side  of  the  bowel, 
or  by  bending  the  bowel  upon  itself  acutely,  and  fixing  it  in  this 
position  with  catgut  sutures. 

Experiment  8.  Dog,  weight  sixty  pounds.  A  wedge-shaped  piece  of  the 
wall  of  the  ileum  was  remoYed  from  the  concave  side  with  a  corresponding 
portion  of  the  mesenteric  attachment,  and  after  arresting  the  bleeding  by 
tying  several  vessels  with  catgut,  the  wound  was  closed  transversely  by  two 
rows  of  sutures.  The  excised  piece  measured  one  inch  at  its  base,  and  the 
apex  reached  as  far  as  the  median  line  of  the  bowel.  Immediately  after 
excision,  the  convex  portion  of  the  bowel  which  had  become  acutely  flexed  by 
uniting  the  wound,  presented  a  livid,  congested  appearance,  and  after  tying 
the  sutures  the  cyanosis  increased.  The  area  of  disturbance  of  the  circulation 
corresponded  to  the  width  of  the  base  of  the  excised  portion.  About  fourteen 
inches  from  this  place  a  similar  piece  was  excised  from  the  convex  side  of  the 
bowel,  and  the  wound  closed  in  the  same  manner.  At  this  point  the  flexion 
was  only  slight,  the  mesenteric  portion  forming  the  prominence  of  the  curve. 
On  the  third  day  the  temperature  rose  to  105.6°  F.,  and  the  foUowing  day  the 
animal  died  with  symptoms  indicative  of  perforative  peritonitis.  On  opening 
the  abdomen,  diffuse  general  peritonitis  was  found  with  numerous  adhesions. 
Gangrene  and  perforation  were  found  on  the  convex  side  directly  opposite  the 
place  of  first  operation.  Second  visceral  wound  closed,  and  lumen  of  bowel 
at  this  point  somewhat  contracted,  but  permeable  to  fluids. 

Experiment  9.  Large,  adult  cat.  Removed  from  convex  side  of  ileum  a 
triangular  piece  measuring  one  inch  at  its  base,  the  apex  reaching  a  little 
beyond  the  middle  line  of  the  bowel.  Wound  closed  transversely  by  Czerny- 
Lembert  sutures.  After  closure  of  the  wound  the  bowel  presented  at  point  of 
partial  resection  an  obtuse  angle,  the  apex  being  formed  by  the  mesenteric 
portion.  The  stools  were  bloody  the  second  day  after  operation.  The  animal 
remained  in  excellent  condition  until  it  was  killed,  forty-three  days  after 
operation.  Adhesions  of  loops  of  small  intestines  to  abdominal  wound,  and 
of  omentum  and  adjacent  intestines  at  point  of  operation.  The  extent  of 
flexion  was  found  somewhat  diminished,  yet  the  concavity  on  convex  side 
of  bowel  was  well  marked.  Size  of  bowel  above  and  below  the  operation  was 
equal,  showing  that  the  flexion  had  not  acted  as  a  cause  of  obstruction.  On 
opening  the  bowel  a  pouch-like  bulging  was  found  on  the  mesenteric  side, 
which  appeared  to  compensate  for  the  narrowing  caused  by  the  artificial 
stenosis.  Two  of  the  deep  sutures  still  remained  attached  to  the  inner  surface 
of  the  bowel. 

Experiment  10.  Large,  adult  cat.  In  this  case  a  loop  of  the  middle  por- 
tion of  the  ileum,  four  inches  in  length,  was  acutely  flexed  in  such  a  manner 
that  the  peritoneal  surfaces  of  the  convex  side  were  brought  in  contact,  and 
in  this  position  the  bowel  was  fixed  by  a  number  of  fine  catgut  sutures.  No 
symptoms  pointing  towards  intestinal  obstruction  were  observed,  and  the 
animal  was  killed  sixteen  days  after  the  operation.  "Wound  was  found  com- 
pletely united,  and  no  signs  of  peritonitis.  The  angle  of  flexion  had  some- 
what diminished,  but  otherwise  the  bowel  was  adherent  in  position  left  after 


VOLVULUS.  151 

operation.  The  bowel  presented  no  dilatation  above  nor  contraction  below  the 
flexion,  showing  that  complete  permeability  of  the  canal  at  the  point  of 
flexion  was  quickly  restored. 

Remarks. — The  partial  excision  on  concave  side  of  bowel  in 
experiment  No.  8,  illustrates  the  danger  of  suturing  wounds  in  this 
locality  where  the  blood  supply  from  the  mesentery  is  likewise 
impaired,  as  gangrene  of  the  remaining  portion  of  the  bowel  is 
almost  certain  to  take  place.  In  all  wounds  on  this  side  of  the 
bowel  more  than  half  an  inch  in  length,  there  is  also  another  great 
danger  which  attends  transverse  suturing,  viz.,  stenosis,  which  may 
become  the  cause  of  intestinal  obstruction.  As  the  small  intestines 
naturally  describe  quite  a  strong  curve  with  the  concavity  on  the 
mesenteric  side,  closure  of  a  wound  involving  this  portion  of  the 
bowel  gives  rise  to  acute  flexion  which,  at  least  during  the  process 
of  healing,  must  cause  more  or  less  obstruction,  until  by  yielding  of 
the  opposite  portion  of  the  intestinal  wall  an  adequate  dilatation 
of  the  calibre  of  the  tube  has  taken  place.  A  considerable  portion  of 
the  wall  on  the  convex  side  of  the  bowel  can  be  removed  and  sutured 
transversely  untU  the  bowel  has  been  transformed  into  a  straight 
tube,  and  a  wound  an  inch  in  length  will  make  only  a  slight  flexion 
which  furnishes  no  serious  mechanical  obstacle  to  the  passage  of  the 
intestinal  contents.  In  this  connection  the  question  arises:  Does 
simple  flexion,  even  if  acute,  without  diminution  of  the  lumen  of  the 
bowel,  give  rise  to  symptoms  of  obstruction  ?  I  have  made  numer- 
ous flexions  when  performing  operations  for  establishing  intestinal 
anastomosis,  and  in  most  instances  satisfied  myself  by  examination 
of  the  specimens  that  fluids  passed  them  without  great  difficulty.  If 
the  bowel  at  the  point  of  flexion  remains  free,  certain  portions  of  its 
wall  will  yield  to  pressure  of  the  fluid  intestinal  contents,  and  grad- 
ually the  lumen  of  the  bowel  will  become  restored.  If,  on  ^he  other 
hand,  the  entire  circumference  of  the  bowel  at  the  point  of  flexion 
has  become  fixed  and  immovable  by  inflammatory  adhesions  or  other 
pathological  products,  a  compensating  dilatation  becomes  impossible, 
and  the  flexion  becomes  a  direct  and  serious  cause  of  obstruction. 

3.     Volvulus. 

This  condition,  only  another  form  of  flexion,  was  experimentally 
produced  by  rotating  a  loop  of  intestine  one  and  a  half  or  two  times 
around  its  axis,  and  retaining  it  in  this  position  by  a  number  of  fine 


152  INTESTINAL  SURGERY. 

sutures,  which  were  applied  in  places  at  the  base  of  the  volvulus, 
where  fixation  was  most  required. 

Experiment  11,  Dog,  weight  twelve  pounds.  A  loop  of  the  ileum,  eight 
inches  in  length,  was  brought  out  through  a  small  incision  and  the  tubes 
turned  around  their  axis  twice  and  the  twist  maintained  by  two  catgut 
sutures.  The  constriction  was  sufficiently  firm  to  cause  considerable  venous 
engorgement  in  the  twisted  loop.  The  dog  manifested  no  unpleasant  symptoms 
after  the  operation.  The  specimen  was  not  obtained,  as  after  a  few  days  the 
dog  ran  away. 

Experiment  12.  Medium-sized  adult  cat.  In  this  case  the  volvulus  was 
made  by  twisting  a  loop  of  the  ileum,  about  four  inches  in  length,  twice 
around  its  axis,  and  retaining  it  in  this  position  by  a  number  of  fine  silk 
sutures.  Vomited  several  times  during  the  first  day.  The  first  three  days  in 
taking  the  temperature  in  the  rectum,  the  thermometer  when  taken  out  was 
bloody.  The  first  two  days  the  temperature  was  normal,  followed  by  an 
increase  to  104.6°  and  103.2'  F.  the  two  succeeding  days;  then  it  became 
normal.  No  constipation;  appetite  good  throughout  the  whole  time.  Animal 
killed  twenty-two  days  after  operation.  Abdominal  wound  completely  united; 
no  peritonitis.  Volvulus  remains  as  after  operation,  with  the  exception  that 
where  the  bowel  had  been  flattened  by  the  twisting  it  had,  at  least  partially, 
resumed  its  tubular  form.  Serous  surfaces  where  approximated  had  become 
firmly  adherent  at  point  of  constriction,  size  of  bowel  considerably  diminished. 
The  twisted  loop  contained  liquid  faeces.  Connecting  the  specimen  with  the 
faucet  of  a  hydrant,  water  could  be  forced  through,  but  on  increasing  the 
force  of  the  current  the  peritoneum  ruptured  extensively  in  a  longitudinal 
direction  to  point  of  partial  obstruction. 

Remakks.— These  experiments  are  interesting,  inasmuch  as  the 
primary  constriction  produced  in  making  and  maintaining  the  volvu- 
lus, which  was  sufficient  to  cause  venous  engorgement  in  the  twisted 
loop,  must  have  been  only  of  short  duration,  the  disappear- 
ance of  the  efPects  of  constriction  being  undoubtedly  due  to  the 
gradual  yielding  of  the  sutured  parts.  While  the  faulty  axis  of  the 
twisted  loop  was  maintained  by  the  sutures,  the  circulation  improved 
and  remained  in  a  sufficiently  vigorous  condition  to  adequately 
nourish  the  most  distant  portions  of  the  volvulus.  While  it  was 
found  difficult  to  force  fluid  through  a  specimen  of  volvulus  during 
life,  propulsion  of  the  intestinal  contents  by  peristaltic  action  was 
carried  on  in  a  satisfactory  manner,  as  the  bowel  above  the  volvulus 
was  not  dilated,  and  contained  no  abnormal  amount  of  fluid,  and  the 
animal  manifested  no  symptoms  indicative  of  intestinal  obstruction. 

4.     Invagination. 
The  most  frequent  and,  from  a  surgical  standpoint,  the  most 
important  form  of  intestinal  obstruction  is  invagination.     Leichten- 


INVAGINATION.  153 

stem  and  Leubuscher  have  made  careful  experimental  studies  to 
explain  the  mechanism  and  pathological  conditions  which  give  rise 
to  this  kind  of  intestinal  obstruction ;  but  in  the  following  experi- 
ments this  part  of  the  subject  was  ignored,  and  the  invaginations 
were  made  by  direct  manipulation.  It  was  found  impossible  to 
make  an  invagination  at  any  point,  as  long  as  the  bowel  was  in  a 
condition  of  contraction,  consequently  it  was  always  found  necessary 
to  wait  until  the  peristaltic  wave  had  passed  by,  or  to  cause  relax- 
ation by  firm  pressure  continued  for  several  minutes.  Usually,  it 
was  found  easy  to  produce  an  invagination  of  the  bowel,  when  in  a 
state  of  relaxation,  by  indenting  one  side  of  the  bowel,  and  pushing 
the  pouch  forward  with  a  blunt  instrument  until  the  entire  lumen  of 
the  intestine  had  passed  into  the  section  of  the  bowel  below.  After 
this  was  accomplished,  further  invagination  was  readily  effected  by 
manipulation,  consisting  in  pushing  gently  the  intussusceptum  and 
intussuscipiens  in  opposite  directions.  After  I  had  learned  by 
experience  that  disinvagination  frequently  takes  place  spontaneously, 
I  resorted  sometimes  to  suturing  of  the  intussusceptum  to  the  neck 
of  the  intussuscipiens  for  the  purpose  of  maintaining  the  invagina- 
tion. But  even  this  expedient  did  not  always  succeed  in  retaining 
the  malposition,  as  spontaneous  reduction  was  observed  in  several  of 
these  cases. 

Experimeyit  13.  Adult  cat.  The  lower  portion  of  the  ileum  and  the 
caecum  and  upper  portion  of  the  colon  were  drawn  forward  into  an  incision 
through  the  linea  alba,  and  five  inches  of  the  ileum  were  pushed  into  the  colon 
through  the  ileo-caecal  valve,  when  the  parts  were  replaced  and  the  abdominal 
wound  closed.  For  six  days  the  animal  had  a  temperature  from  102.6°  to 
105°  F.,  and  suffered  from  tenesmus.  The  stools  contained  mucus  and  blood. 
After  the  sixth  day  the  symptoms  due  to  invagination  subsided,  and  were 
replaced  by  symptoms  of  peritonitis.  The  animal  was  killed  twenty-two  days 
after  operation.  Great  emaciation  ;  abdominal  wound  completely  united; 
diffuse  purulent  peritonitis.  The  disease  had  evidently  commenced  in  the 
ileo-csecal  region,  as  at  this  point  the  pathological  changes  were  found  most 
advanced.  Complete  spontaneous  reduction  of  the  invagination ;  colon 
greatly  distended,  and  intensely  congested. 

Experiment  14.  Large,  adult  cat.  Invagination  was  made  in  the  lower 
part  of  the  ileum.  Length  of  intussusceptum  three  inches.  For  nine  days 
the  scanty  fsecal  discharges  contained  mucus  and  at  times  blood.  On  the 
ninth  day  the  temperature  registered  105°  F.  ;  absolute  refusal  of  food,  and 
only  occasional  vomiting  ;  death  on  the  thirty-third  day  after  invagination. 
Abdominal  wound  healed  ;  small  ventral  hernia  ;  no  peritonitis.  Apparently, 
the  greater  portion  of  the  intussusceptum  had  disappeared  by  sloughing,  and 


154  INTESTINAL  SURGERY. 

•31 

the  subsequent  healing  process  had  produced  an  acute  flexion  at  the  neck  of  the 
intussuscipiens.  Firm  adhesions  between  peritoneal  surfaces  in  the  concavity 
of  the  flexion,  nearly  an  inch  in  length.  Above  this  point  the  intestine  was 
enormously  dilated  and  distended  with  fluid  contents.  Below  the  obstruction 
the  bowel  was  found  contracted  and  empty.  Water  could  not  be  forced 
through  the  obstruction  from  either  direction.  On  slitting  open  the  bowel  in  a 
longitudinal  direction,  it  was  found  that  the  lumen  at  the  point  of  flexion  was 
contracted  to  such  an  extent  that  only  a  fine  probe  could  be  passed.  On  the 
concave  side  of  the  flexion  the  mucous  membrane  presented  a  prominence 
marked  by  a  number  of  longitudinal  ridges.  These  folds  had  undoubtedly 
acted  like  valves  in  completely  preventing  the  passage  of  intestinal  contents, 
and  later,  the  injection  of  water.  Death  in  this  case  resulted  from  intestinal 
obstruction  caused  by  cicatricial  contraction  after  the  sloughing  of  the  invagi- 
nated  portion  of  the  bowel. 

Experiment  15.  Adult  cat.  Two  inches  of  the  ileum  were  invaginated 
into  the  colon  and  fixed  by  two  fine  silk  sutures  at  the  neck  of  the  intussus- 
cipiens. For  two  days  after  the  invagination  the  stools  were  scanty  and 
contained  mucous  and  blood.  On  the  third  day  the  abdominal  cavity  was 
re-opened  by  an  incision  along  the  outer  border  of  the  right  rectus  muscle,  and 
the  invaginated  bowel  drawn  forward  into  the  wound.  No  peritonitis.  The 
bowel  at  point  of  operation  was  very  vascular,  and  the  neck  of  the  intussus- 
cipiens covered  with  plastic  exudation.  The  sutures  were  removed  and  the 
rectum  and  colon  distended  with  water  for  the  purpose  of  effecting  reduction. 
As  soon  as  the  colon  had  become  thoroughly  distended  the  adhesions  gave 
way  with  an  audible  noise,  and  complete  reduction  followed  in  such  a  manner 
that  the  portion  last  invaginated  was  first  reduced.  After  reduction  had  been 
accomplished  the  injection  was  continued  to  test  the  competency  of  the  ileo- 
caecal  valve.  As  soon  as  the  caecum  was  well  distended  the  fluid  passed  readily 
through  the  valve  into  the  small  intestines,  showing  that  the  valve  had  been 
rendered  incompetent  by  the  invagination.  The  force  required  to  overcome 
the  adhesions  in  the  reduction  of  the  invagination  was  sufficient  to  rupture 
the  peritoneal  covering  of  the  large  intestines  in  three  different  places,  the 
rents  always  taking  place  parallel  to  the  bowel.  The  animal  died  on  the 
following  day  with  symptoms  of  diffuse  peritonitis. 

Experiment  16.  Ascending  invagination  in  a  cat.  A  few  inches  above 
the  ileo-caecal  region  the  ileum  was  invaginated  in  an  upward  direction  to  the 
extent  of  two  inches.  At  the  time  the  invagination  was  made  the  intussus- 
cipiens contracted  firmly.  In  consequence  of  this,  a  tear  occurred  in  its  peri- 
toneal covering  in  a  direction  parallel  to  the  bowel.  The  stools  were  few  and 
scanty.  On  the  fourth  day  the  animal  died  of  perforative  peritonitis.  Abdom- 
inal wound  not  united,  but  the  peritoneal  wound  closed  by  omental  adhesions. 
Spontaneous  reduction  of  half  an  inch  of  the  invagination  had  taken  place. 
Reduction  by  traction  was  found  impossible  on  account  of  firm  adhesions 
about  the  neck  of  the  invagination.  Recent  diffuse  peritonitis  caused  by  two 
perforations,  one  at  the  neck  of  the  intussusceptum  on  mesenteric  side,  and 
the  other  a  little  to  one  side  of  this  one  and  on  proximal  side  of  the  bowel. 


INVAGINATION.  155 

The  perforation  resulted  from  beginning  sloughing  of  the  invaginated  portion 
of  the  bowel.  About  two  inches  above  the  invagination  the  bowel  was  acutely 
flexed  towards  the  mesenteric  side  by  recent  firm  adhesions.  Flexion  was 
undoubtedly  caused  by  circumscribed  plastic  peritonitis  and  increased  peri- 
stalsis. 

Experiment  17,  Large,  adult  cat.  Descending  invagination  of  ileum  to 
the  extent  of  two  inches  in  the  upper  portion  of  this  part  of  the  bowel. 
Second  and  third  days  the  scanty  discharges  from  the  bowel  bloody.  Temper- 
ature from  second  day  after  operation  varied  between  103.4°  and  105.4°  F. 
Death  from  perforative  peritonitis  on  the  seventh  day  after  invagination. 
Abdominal  wound  united.  Recent  diffuse  peritonitis  from  a  perforation  at 
the  neck  of  the  invagination  on  the  mesenteric  side.  Gangrene  of  intussus- 
ceptum  and  partial  separation  which  had  again  caused  a  sharp  flexion  of  the 
bowel  at  the  neck  of  the  invagination.  Above  the  seat  of  obstruction  the 
bowel  dilated  and  distended  with  fluid  contents;  below  empty  and  contracted. 

Experiment  18.  Young  cat.  Invagination  of  ileum  into  ascending  colon 
to  the  extent  of  three  inches.  For  a  week  after  operation  frequent  tenesmus, 
followed  by  mucous  discharges  mixed  with  blood.  The  temperature  during 
this  time  varied  from  102.6°  to  105°  F.  After  this  the  animal  improved  and 
was  in  good  condition  when  killed  fourteen  days  after  operation.  Abdominal 
wound  united.  No  omental  adhesions  or  peritonitis.  Firm  union  between  the 
eerous  surfaces.  No  dilatation  of  bowel  above  seat  of  obstruction.  Intussus- 
ceptum  not  gangrenous,  its  lumen  about  the  size  of  an  ordinary  lead-pencil. 
It  was  found  impossible  to  reduce  the  invagination  by  traction  or  by  forcible 
injection  of  fluid  from  below.  When  the  traction  was  increased,  the  peritoneal 
surface  of  the  neck  of  the  intussuscipiens  ruptured  in  a  longitudinal  direction. 

Experiment  19.  Large,  adult  cat.  Six  inches  of  the  ileum  were  invagi- 
nated into  the  colon.  Frequent  bloody  discharges  until  the  third  day,  when 
the  abdomen  was  reopened  and  the  neck  of  the  intussuscipiens  exposed  to 
sight,  so  as  to  observe  directly  the  mechanism  of  disinvagination  by  rectal 
injection  of  water.  As  soon  as  the  colon  was  well  distended  the  adhesions  at 
the  neck  of  the  intussuscipiens  began  to  give  way,  and  complete  reduction 
followed,  as  the  adhesions  gave  way  under  the  pressure  from  below.  The 
abdominal  wound  was  again  closed  and  dressed  in  the  usual  manner.  The 
animal  recovered  completely  from  the  operation,  and  was  killed  twenty-four 
days  after  the  first  operation.  Abdominal  wound  well  united.  In  the  ileo- 
caBcal  region,  numerous  adhesions  around  the  portion  of  bowel  which  had  been 
invaginated  and  subsequently  reduced. 

Experiment  20.  Invagination  of  colon  into  colon  was  commenced  about 
the  middle  of  the  bowel,  and  advanced  as  far  as  the  caecum.  Second  day  bloody 
discharges  from  the  bowels.  Animal  killed  five  days  after  operation.  External 
wound  united  only  on  peritoneal  side.  Invagination  completely  reduced. 
Localized  plastic  peritonitis  limited  to  the  portion  of  the  bowel  which  had 
been  invaginated;  otherwise  peritoneum  and  intestines  in  a  healthy  condition. 

Experiment  21.  Invagination  of  colon  into  colon  to  the  extent  of  four 
inches,  in  a  cat.     The  subsequent  symptoms  only  for  a  short  time  indicated 


156  INTESTINAL  SURGERY, 

the  existence  of  invagination,  which  after  they  had  subsided,  were  followed  by 
evidence  of  peritonitis.  Death  occurred  on  the  nineteenth  day  after  the 
invagination.  Abdominal  wound  well  united;  diffuse  purulent  peritonitis; 
under  surface  of  diaphragm  covered  with  plastic  lymph.  Although  sought 
for,  no  perforation  could  be  found  in  the  disinvaginated  bowel,  but  as  the 
peritonitis  appeared  to  have  started  at  the  site  of  operation,  it  is  probable 
that  infection  took  place  through  the  paretic  walls  of  the  disinvaginated  bowel. 
Experiment  22.  Same  kind  of  invagination  made  in  a  cat  as  in  the 
preceding  case.  For  two  days  the  stools  were  frequent,  scanty,  and  contained 
mucus  and  blood.  After  this  the  animal  remained  in  good  condition  until  it 
was  killed  thirty-five  days  after  the  invagination.  Abdominal  cavity  showed 
no  trace  of  inflammation.  The  invagination  was  completely  reduced  and  the 
entire  colon  presented  a  normal  appearance. 

Remakks. — With  the  exception  of  experiment  No.  16,  the  in- 
vagination was  always  made  in  a  downward  direction.  In  the  case 
of  ascending  invagination,  gangrene  of  the  intussusceptum  and 
perforation  resulted  in  death  from  diffuse  peritonitis  on  the  fourth 
day  after  partial  spontaneous  reduction  had  taken  place.  In  experi- 
ments Nos.  15  and  19,  both  cases  of  ileo-csecal  invagination, 
complete  reduction  was  effected  by  distention  of  the  colon  with 
water ;  in  the  first  case  the  force  required  to  accomplish  this  result 
was  sufficient  to  produce  multiple  longitudinal  lacerations  of  the 
peritoneal  surface  of  the  distended  bowel,  which  undoubtedly  were 
responsible  for  the  death  on  the  following  day  from  diffuse  perito- 
nitis ;  while  in  the  second  case  no  such  accident  occurred,  and  the 
animal  recovered,  although  the  abdominal  wound  was  re-opened  for 
the  purpose  of  observing  the  mechanism  of  reduction  by  this  method 
of  procedure.  In  one  case  of  ileo-csecal  invagination,  experiment 
No.  18,  the  intussusceptum  remained  in  situ  after  the  invagination, 
and  became  so  firmly  adhere  ^t  to  the  intussuscipiens  that  even  in 
the  specimen,  reduction  by  traction  was  found  impossible.  In  this 
case,  although  the  lumen  of  the  invaginated  portion  barely  permitted 
the  introduction  of  an  ordinary  lead  pencil,  no  symptoms  of  obstruc- 
tion were  manifested  during  life,  and  the  bowel  above  the  invagina- 
tion was  not  found  dilated  after  death.  In  experiment  No.  14,  the 
sloughing  of  the  intussusceptum  led  to  cicatricial  contraction  of  the 
bowel  and  flexion  at  site  of  invagination,  conditions  which  resulted 
in  death  from  obstruction  twenty-three  days  after  invagination. 

The  great  danger  which  attends  sloughing  of  the  invaginated 
portion  is  circumscribed  gangrene  and  perforation  of  the  intussus- 
cipiens  at   the   neck,   and   death  from   perforative  peritonitis,  as 


PERMEABILITY   OF  ILEO-CMCAL    VALVE.  157 

illustrated  by  experiments  Nos.  16  and  17.  Experiment  No.  16 
illustrates  that  ascending  invagination,  should  it  occur,  is  not  more 
likely  to  be  reduced  spontaneously  than  the  more  common  form  of 
descending  invagination.  These  experiments  also  demonstrate 
conclusively  that  the  danger  attending  the  invagination  increases  the 
higher  it  is  located  in  the  intestinal  canal,  being  greatest  when  it  is 
situated  high  up  in  the  tract  of  the  small  intestines,  and  gradually 
less  as  the  ileo-csecal  region  is  approached.  The  ileo-csecal  form  is 
less  dangerous,  as  spontaneous  reduction  is  more  likely  to  take 
place;  and  gangrene  of  the  intussusceptum,  when  it  occurs,  does  so 
after  a  longer  time,  after  firm  adhesions  about  the  neck  of  the  intus- 
suscipiens  have  formed,  a  condition  which  is  well  adapted  to  prevent 
perforation.  Of  the  three  invaginations  of  the  colon,  experiments 
Nos.  20,  21  and  22,  complete  spontaneous  reduction  took  place  in 
all  of  them  from  the  first  to  the  fourth  day,  and  in  only  one  of  them 
was  the  result  fatal,  in  experiment  No.  21,  where  purulent  perito- 
nitis, either  from  infection  through  the  operation  wound  or,  what  is 
more  probable,  through  the  damaged  wall  of  the  colon  occurred, 
and  was  the  cause  of  death  on  the  nineteenth  day  after  the  invagi- 
nation. Experiments  Nos.  15  and  19  prove  both  the  danger  and 
the  utility  of  distention  of  the  colon  in  cases  of  ileo-csecal  and 
colonic  invaginations.  As  a  rule,  the  longer  the  invagination  has 
existed  the  firmer  the  adhesions,  and  consequently  the  greater  the 
danger  of  relying  too  persistently  on  this  measure  in  reducing  the 
invagination.  In  resorting  to  this  expedient  in  the  reduction  of  an 
ileo-c^ecal  invagination,  it  is  of  the  greatest  importance  to  relax  the 
abdominal  wall  completely  by  placing  the  patient  fully  imder  the 
influence  of  an  anaesthetic;  and  to  add  to  the  distending  force  as 
much  as  possible  by  gravitation,  the  patient  should  be  inverted  and 
the  injection  should  always  be  made  very  slowly  and  with  requisite 
care  to  prevent  rupture  of  the  peritoneal  coat  by  rapid  over-disten- 
tion.  When  the  obstruction  is  located  beyond  the  ileo-csecal  valve, 
no  reliance  can  be  placed  upon  this  measure,  as  can  be  seen  from 
the  following  experiments  made  to  determine  the 

Permeability  of  the  Ileo-Caecal  Valve. 

Experiment  23.  While  completely  under  the  influence  of  ether  an  incision 
was  made  through  the  linea  alba  of  a  cat,  sufiiciently  long  to  render  the 
ileo-csecal  region  readily  accessible  to  sight.  An  incision  was  made  into 
the  ileum  just  above  the  valve,  and  by  gently  retracting  the  margins  of  the 


158  INTESTINAL  SURGERY. 

■wound,  the  valve  could  be  distinctly  seen;  water  was  then  injected  per  rectum, 
and  as  the  caecum  became  well  distended,  it  could  be  readily  seen  that  the  valve 
became  tense  and  appeared  like  a  circular  curtain  preventing  effectually  the 
escape  of  even  a  drop  of  fluid  into  the  ileum.  The  competency  of  the  valve 
was  only  overcome  by  over -distention  of  the  caecum  which  mechanically 
separated  its  margins,  which  allowed  a  fine  stream  of  water  to  escape  into  the 
ileum.  The  insufBciency  of  the  valve  was  clearly  caused  by  great  distention 
of  the  caecum.  That  such  a  degree  of  distention  is  attended  by  no  incon- 
siderable danger  was  proved  by  this  experiment,  as  the  cat  was  immediately 
killed,  and  on  examination  of  the  colon  and  rectum  a  number  of  longitudinal 
rents  of  the  peritoneal  coat  were  found. 

ExperimeAit  24.  In  this  experiment,  a  cat  was  fully  narcotized  with  ether 
and  while  the  body  was  inverted  water  was  injected  per  rectum  in  sufficient 
quantity,  and  adequate  force  by  means  of  an  elastic  syringe,  to  ascertain  the 
force  required  to  overcome  the  resistance  offered  by  the  ileo-caecal  valve. 
Great  distention  of  the  caecum  could  be  clearly  mapped  out  by  percussion  and 
palpation  before  any  fluid  passed  into  the  ileum.  As  soon  as  the  competency 
of  the  valve  was  overcome,  the  water  rushed  through  the  small  intestines, 
and  having  traversed  the  entire  alimentary  canal  issued  from  the  mouth. 
About  a  quart  of  water  was  forced  through  in  this  ruanner.  The  animal  was 
killed  and  the  gastro-intestinal  canal  carefully  examined  for  injuries.  Two 
longitudinal  lacerations  of  the  peritoneal  surface  of  the  rectum,  over  an  inch 
in  length,  were  found  on  opposite  sides  of  the  bowel. 

Experiment  25.  This  experiment  was  conducted  in  the  same  way  as  the 
foregoing,  only  that  the  cat  was  not  etherized.  More  than  a  quart  of  water 
was  forced  through  the  entire  alimentary  canal  from  anus  to  mouth.  The 
animal  was  not  killed,  and  lived  for  eight  days,  but  suffered  the  whole  time 
with  symptoms  of  ileo-colitis.  A  post-mortem  examination  was  not  made  in 
this  case,  although  the  symptoms  manifested  during  life  leave  no  doubt  that 
they  resulted  from  injuries  inflicted  by  the  injection.  It  will  thus  be  seen 
that  in  the  three  cases  where  fluid  was  forced  beyond  the  ileo-caecal  valve,  in 
two  of  them  the  post-mortem  examination  revealed  multiple  lacerations  of 
the  peritoneal  coat  of  the  large  intestines,  while  the  third  animal  sickened 
immediately  kfter  the  experiment  was  made,  and  died  from  tho  effects  of  the 
injuries  inflicted  eight  days  later.  The  injection  of  water  beyond  the  ileo- 
caecal  valve  in  the  treatment  of  intestinal  obstruction  must  therefore  be  looked 
upon  in  the  light  of  a  dangerous  expedient  and  should  never  be  resorted  to. 

II.    Enterectomy. 

It  still  remains  an  open  question  to  what  extent  resection  of  the 
small  intestines  can  be  performed  with  impunity.  It  is  true  that 
Koeberl^,  Kocher  and  Baum  have  successfully  removed  respectively 
205  cm.,  160  cm.,  and  137  cm.  of  the  small  intestine  in  the  human 
subject;  but  while  two  of  the  patients  do  not  appear  to  have  suffered 
any  ill  effects  in  consequence  of  the  removal  of  such  a  large  surface 


ENTERECTOMY.  159 

for  digestion  and  absorption,  in  Baum's  case  death,  whicli  super- 
vened six  months  after  the  operation,  was  attributable  clearly  to 
marasmus,  brought  about  by  the  extensive  intestinal  resection.  As 
in  a  number  of  pathological  conditions  of  the  intestinal  canal,  where 
the  wounds  are  large  and  in  close  proximity,  such  as  multiple  strict- 
ures, gangrene,  and  multiple  gunshot  woiinds,  it  may  be  necessary 
to  resort  to  extensive  resection,  it  becomes  an  important  matter  for 
the  sursreon  to  know  how  much  of  the  intestinal  tract  can  be  removed 
without  any  immediate  or  remote  ill  consequences. 

The  immediate  danger  attending  such  an  operation  is  the 
traumatism,  which  of  course,  will  be  proportionate  to  the  length  of 
the  piece  of  intestine  removed;  while  the  remote  consequences  are 
due  to  impairment  of  the  functions  of  digestion  and  absorption 
caused  by  the  shortening  of  the  intestinal  canal.  With  the  view  of 
obtaining  additional  light  on  these  important  questions  the  following 
experiments  were  undertaken : 

Experiment  26.  Dog,  weight  twenty-two  pounds.  Mesentery  divided  into 
four  portions  and  tied  with  catgut,  and  thirty  inches  of  the  ileum  from  near 
the  ileo-caecal  region  upwards  excised,  and  ends  sutured  together  by  Czerny- 
Lembert  sutures.  Abdominal  wound  failed  to  unite,  and  a  copious  sero- 
sanguinolent  discharge  escaped  from  it  the  last  day.  Death  on  fifth  day  from 
peritonitis.  Peritoneal  adhesions  in  abdominal  wound  only  partial;  omentum 
adherent  to  wound.  Intestines  firmly  adherent  to  omental  stump.  Circum- 
scribed gangrene  of  bowel  on  convex  side  at  site  of  operation.  Recent  diffuse 
peritonitis  caused  by  perforation. 

Experiment  27.  In  a  cat,  twelve  inches  were  removed  from  the  middle  of 
the  ileum,  and  the  ends  united  by  a  double  row  of  sutures;  mesenteric  vessels 
tied  en  masse  with  one  catgut  suture.  The  animal  never  rallied  from  the 
operation,  and  died  of  the  shock  the  same  night. 

Experim,ent  28.  Dog,  weight  thirty-six  pounds.  Mesentery  tied  in  several 
sections  with  catgut  ligatures;  ileum  divided  just  above  the  ileo-csecal  valve 
and  six  feet  of  the  small  intestines  excised,  and  the  ends  united  by  Czerny- 
Lembert  sutures.  On  the  third  day  the  fascal  discharges  were  bloody.  Although 
the  appetite  remained  good,  and  the  dog  was  allowed  to  eat  as  much  as  l>e 
desired,  he  lost  several  pounds  in  weight  during  the  first  week.  On  the  third 
day  the  abdominal  wound  opened  as  the  sutures  had  cut  through  and  required 
re-suturing.  After  this  time  the  wound  healed  kindly.  Three  or  four  fluid 
faecal  discharges  during  twenty -four  hours.  The  character  of  the  discharges 
remained  the  same,  and  several  microscopic  examinations  made  at  different 
times  revealed  the  presence  of  free  undigested  fat.  The  dog  was  kept  busy  eat- 
ing most  of  the  time,  and  although  the  most  nourishing  food  was  furnished,  he 
emaciated  to  a  skeleton.  He  was  killed  one  hundred  and  sixty-one  days  after 
the  operation.     Marasmus  extreme,  hardly  a  trace  of  fat  could  be  found  any- 


160  INTESTINAL  SURGERY. 

where  in  the  tissues.  Stomach  enlarged  to  three  or  four  times  its  normal  size, 
and  distended  with  food.  A  slight  thickening  of  the  wall  of  the  gut  indicated 
externally  the  site  of  suturing,  and  the  lumen  of  the  bowel  at  this  point  was 
slightly  diminished  in  size.  At  point  of  operation  a  loop  of  intestine  was 
found  adherent  and  somewhat  contracted.  The  remaining  portions  of  the 
small  intestines,  only  forty-five  inches  in  length,  seemed  to  have  undergone 
compensatory  hypertrophy,  as  the  coats  were  much  thickened  and  exceedingly 
vascular.  At  the  seat  of  suturing,  the  mucous  membrane  presented  a  slight 
circular  prominence.  Pancreas,  liver  and  spleen  were  normal  in  size  and 
appearance. 

Experiment  29.  Medium-sized,  adult  dog.  Mesentery  tied  in  several 
sections,  and  eight  feet  and  two  inches  of  the  small  intestines  from  ileo-csecal 
region  upwards  excised  and  ends  sutured  in  the  usual  manner.  On  the  follow- 
ing day  the  dog  vomited,  and  blood  was  seen  to  escape  from  the  abdominal 
wound.  Death  three  days  after  operation.  The  abdominal  cavity  was  filled 
with  fluid  and  coagulated  blood,  which  on  closer  inspection  was  found  to  have 
escaped  from  one  of  the  stumps  of  the  mesentery,  where  the  catgut  ligature 
had  slipped  ofif. 

Experiment  30.  Scotch  terrier,  weight  ten  pounds.  Mesentery  ligated  in 
part  with  catgut  ligatures,  the  ileum  divided  four  inches  above  the  ileo- 
caacal  region,  and  fifty  inches  of  the  small  intestines  excised,  and  the  continu- 
ity of  the  intestinal  canal  restored  by  the  usual  method  of  suturing.  Some 
difficulty  was  experienced  in  suturing,  as  the  lumen  of  the  upper  end  was 
considerably  larger  than  that  of  the  lower.  Until  four  weeks  after  the  opera- 
tion the  dog,  although  eating  well,  seemed  to  become  more  and  more  emaci- 
ated. After  this  time  he  gained  somewhat  in  weight  until  killed  forty-seven 
days  after  the  resection.  During  the  whole  time  the  faeces  were  either  fluid 
or  only  semi-solid,  and  at  different  times  contained  free,  undigested  fat. 
Appetite  most  of  the  time  voracious.  No  adhesions  to  abdominal  wound. 
Omentum  adherent  to  visceral  wound  and  to  bowel.  The  site  of  operation  was 
indicated  by  a  slight  depression  on  the  surface  of  the  bowel.  On  palpation  a 
ring-like  thickening  was  felt  corresponding  to  the  united  ends  of  the  bowel. 
Bowel  above  seat  of  resection  somewhat  enlarged.  On  cutting  into  the  bowel, 
the  point  of  union  was  indicated  by  a  circular  prominence  of  mucous  mem- 
brane. Nine  of  the  deep  sutures  were  found  still  attached  to  the  mucous 
membrane.  The  entire  tract  of  the  small  intestines  which  remained  measured 
oniy  two  feet  and  ten  inches  in  length. 

Experiment  31.  Adult  Maltese  cat.  The  mesentery  was  tied  in  five 
sections  with  catgut  ligatures  corresponding  to  twenty-nine  inches  of  the 
ileum  which  was  excised.  Previous  experience  in  circular  enterorrhaphy  had 
satisfied  me  that  perforation  is  most  likely  to  take  place  on  the  mesenteric 
side  of  the  bowel,  where,  on  account  of  the  triangular  place  made  by  the 
reflections  of  the  peritoneum,  the  muscular  coat  is  not  covered  by  serous 
membrane.  To  obviate  this  difficulty  I  secured  a  continuity  of  the  serous 
covering  of  the  ends  of  the  bowel  before  suturing,  by  drawing  the  peritoneum 
over  this  raw  surface  by  a  fine  catgut  suture.     The  mesentery  was  detached 


EXCISION  OF  COLON.  161 

only  to  a  sufficient  extent  to  apply  the  second  row  of  sutures.  The  fine  catgut 
suture  to  approximate  the  edges  of  the  peritoneum  was  applied  near  the 
margin  of  the  divided  end  of  the  bowel,  so  that  the  knot  did  not  interfere 
with  the  accurate  coaptation  of  the  serous  surface  between  the  deep  and 
superficial  row  of  sutures.  This  modification  of  circular  suturing  was  adopted 
for  the  first  time  in  this  case.  Although  the  animal  manifested  no  untoward 
symptoms,  and  the  appetite  remained  good,  the  marasmus  was  progressive 
until  the  time  of  killing,  twelve  days  after  the  excision.  Abdominal  wound 
not  completely  united.  Intestinal  wound,  which  was  two  inches  above  the 
ileo-caecal  region,  completely  healed.  The  sutured  surface  was  adherent  to  a 
loop  of  bowel  which  caused  a  sharp  flexion.  Intestine  above  this  point  some- 
what dilated  and  partially  distended  with  faecal  accumulation.  Slight  contrac- 
tion of  the  lumen  of  bowel  by  circular  bulging  of  mucous  membrane,  in 
which  most  of  the  deep  sutures  remained  fixed.  The  post-mortem  appear- 
ance pointed  to  partial  obstruction  at  point  of  flexion;  remaining  portion  of 
small  intestines  measured  only  twenty-one  inches  in  length. 

Experiment  32.  Medium-sized  Maltese  cat.  Mesentery  tied  in  sections, 
and  thirty-four  inches  of  the  small  intestines  excised  and  the  divided  ends 
united  in  the  same  manner  as  in  the  last  case,  special  care  being  taken  to 
secure  an  uninterrupted  peritoneal  surface  for  divided  ends  before  suturing. 
Appetite  remained  good,  but  progressive  marasmus,  which  appeared  at  once, 
continued  and  proved  the  direct  cause  of  death  twenty-one  days  after  the 
excision.  Abdominal  wound  firmly  united.  No  peritonitis.  Visceral  wound 
completely  united;  intestine  at  site  of  operation  covered  with  adherent 
omentum. 

I.    Excision  of  Colon. 

Experiment  33.  Large,  black  cat.  The  meso-colon  was  divided  in  numer- 
ous sections,  and  each  part  separately  tied  with  a  catgut  ligature.  As  the 
meso-colon  was  very  short,  a  number  of  the  ligatures  slipped  off  and  had  to  be 
replaced  by  fine  silk  ligatures.  The  entire  colon  and  about  two  inches  of  the 
lower  end  of  the  ileum  were  excised.  As  it  was  found  impossible  to  unite  the 
bowel  on  account  of  the  deep  location  of  the  rectal  end,  it  became  necessary 
to  close  the  distal  or  rectal  end  by  inverting  its  margins  and  applying  a 
continuous  suture.  An  artificial  anus  was  established  by  stretching  the  iliac 
or  proximal  end  into  the  abdominal  wound.  Death  from  shock  a  few  hours 
after  the  operation. 

Experiment  3i.  Medium-sized  dog.  Resection  of  entire  colon  and  three 
inches  of  ileum.  Meso-colon  divided  into  sections  and  ligated  with  silk 
ligatures.  In  order  to  enable  circular  enterorrhaphy  it  was  found  necessary  to 
excise  a  triangular  piece  from  large  distal  end,  so  as  to  make  its  lumen  corres- 
pond to  that  of  the  divided  ileum.  After  this  was  done  and  the  lateral  wound 
closed  by  two  rows  of  sutures,  the  ends  of  the  bowel  were  united  in  the  usual 
manner.     Death  from  shock  six  hours  after  operation. 

Experiment  35.  Excision  of  entire  colon  and  two  inches  of  ileum  in  a 
oat.  Excision  of  triangular  piece  from  distal  end,  to  narrow  the  bowel  suffi- 
11 


162  INTESTINAL  SURGERY. 

ciently  so  that  its  lumen  should  correspond  to  that  of  the  ileum.  The  ileum 
and  rectum  were  then  united  by  Czerny-Lembert  sutures.  The  animal  never 
rallied  from  the  prolonged  operation,  and  died  of  shock  two  hours  later. 

Remarks. — The  results  of  these  experiments  speak  for  them- 
selves. In  all  cases  of  extensive  resection  of  the  small  intestines 
where  the  resected  portion  exceeded  one-half  of  the  length  of  this 
portion  of  the  intestinal  tract,  where  the  animals  survived  the 
operation,  marasmus  followed  as  a  constant  result,  although  the 
animals  consumed  large  quantities  of  food.  In  all  of  these  cases 
defective  digestion  and  absorption  could  be  directly  attributed  to  a 
degree  of  shortening  of  the  digestive  canal  imcompatible  with 
normal  digestion  and  absorption.  Only  one  of  these  animals 
(experiment  No.  27)  died  from  shock  a  few  hours  after  operation. 
Another  death  resulted  from  the  trauma,  in  experiment  No.  29, 
where  fatal  haemorrhage  occurred  from  one  of  the  mesenteric  vessels, 
where  the  catgut  ligature  became  displaced  from  shrinkage  of  the 
included  mesenteric  tissues.  When  the  vessels  of  the  omentum  or 
mesentery  are  tied  en  masse  there  is  always  danger  from  this  source, 
and  to  prevent  this  accident  it  becomes  necessary  not  to  include  too 
much  tissue,  and  to  tie  firmly  with  fine  threads  of  aseptic  silk. 
After  I  commenced  to  tie  in  this  manner,  I  encountered  no  further 
dijQficulty  in  arresting  and  preventing  hsemorrhage  in  operations 
requiring  incision  of  these  tissues.  Although  the  large  artery 
running  parallel  with  the  bowel  where  the  mesentery  is  attached  was 
excised  in  every  case  with  the  intestine,  gangrene  and  perforation 
occurred  only  in  experiment  No.  26.  The  post-mortem  appearances 
after  extensive  enterectomies  indicated  that  the  portion  of  bowel 
which  remained  underwent  compensatory  hypertrophy,  but  that  as  a 
rule  the  increased  functional  activity  was  not  adequate  to  make  up  for 
the  great  anatomical  loss.  In  all  instances  where  the  animal  recovered 
from  the  operation,  the  discharges  from  the  bowels  were  frequent, 
fluid  or  semi-fluid,  and  contained  undigested  food,  among  other 
substances,  free  undigested  fat,  showing  that  the  intestinal  secretions 
play  an  important  role  in  the  digestion  of  fat.  As  an  approximate 
estimate  the  statement  can  be  ventured  that  in  dogs  and  cats,  the 
excision  of  more  than  one-third  of  the  length  of  the  small  intestines 
is  dangerous  to  life,  as  it  is  followed  by  marasmus,  which  sooner  or 
later  results  in  death.  As  all  three  cases  of  excision  of  the  colon 
proved  fatal  from  shock  in  from  two  to  six  hours,  it  can  be  safely 


PHYSIOLOGICAL  EXCLUSION.  163 

asserted   that   this   operation   is   impracticable,    and   is    invariably 
followed  by  death  from  the  immediate  results  of  the  trauma. 

2.     Physiological  Exclusion. 

As  extensive  resections  of  the  intestines  are  always  attended  by 
great  risks  to  life  from  the  trauma,  I  concluded  to  study  the  subject 
of  sudden  deprivation  of  the  system  of  a  great  surface  for  digestion 
and  absorption,  by  eliminating  or  diminishing  the  cause  of  death  from 
this  source  by  leaving  the  intestine,  but  by  excluding  permanently 
a  certain  portion  from  participating  in  the  functions  of  digestion  and 
absorption;  in  other  words,  by  resorting  to  physiological  exclusion. 
These  experiments  were  also  made  to  determine  the  tissue  changes 
which  would  take  place  in  the  bowel  thus  excluded,  and  to  learn  if 
under  such  circumstances  accumulation  of  intestinal  contents  would 
become  a  source  of  danger,  as  had  been  feared  by  the  older  surgeons. 
The  complete  interruption  of  passage  of  intestinal  contents  either  by 
section  and  closure  of  the  bowel,  or  by  making  an  intestinal  obstruc- 
tion of  some  kind,  and  the  restoration  of  the  continuity  of  the 
physiologically  active  portion  of  the  intestinal  canal,  was  established 
by  suturing  the  proximal  end  of  the  high  section  with  the  distal 
end  of  the  lower  section,  or  by  implanting  the  proximal  end  into  the 
bowel  lower  down,  the  intervening  portion  of  the  intestinal  tract  in 
either  case  thus  becoming  the  excluded  portion. 

Experiment  36.  Large  cat,  -weight  nine  pounds.  Double  division  of  small- 
intestines,  upper  section  made  about  eight  inches  below  the  pylorus,  and 
the  lower  three  feet  lower  down ;  the  portion  of  bowel  between  these  circular 
sections  was  closed  at  both  ends,  and  the  continuity  of  the  intestinal  canal 
restored  by  suturing  the  open  ends  in  the  usual  manner.  In  this  way  three 
feet  of  the  small  intestines  were  isolated  and  completely  excluded  from  the 
digestiYe  canal.  The  intervening  portion  was  emptied  of  its  contents  as 
completely  as  possible  before  its  ends  were  closed  by  suturing.  The  animal 
died  on  the  fourth  day  after  the  operation.  A  small  perforation  of  the  sutured 
bowel  on  the  mesenteric  side  was  found,  otherwise  the  -visceral  wound  was 
found  well  united.  The  perforation  had  given  rise  to  diffuse  peritonitis  which 
was  the  immediate  cause  of  death. 

Experiment  37.  Dog,  weight  thirty-two  pounds.  The  jejunum  was  divided 
four  feet  above  the  ileo-csecal  region,  and  the  distal  end  closed.  Jejuno-colos- 
tomy  was  made  by  implanting  the  proximal  end  into  a  slit  made  in  the 
convex  side  of  the  ascending  colon,  large  enough  to  correspond  to  the 
circumference  of  the  jejunum.  The  implanted  end  was  fixed  in  its  position 
by  two  rows  of  sutures.  The  animal  never  appeared  to  rally  from  the  effects 
of  the  operation,  and  died  at  the  end  of  the  next  day.     The  abdominal  cavity 


164  INTESTINAL  SURGERY. 

was  found  filled  with  blood,  which  must  have  escaped  from  a  mesenteric 
vessel,  from  which  probably  the  catgut  ligature  had  slipped.  The  excluded 
portion,  that  is,  that  portion  intervening  between  the  circular  section  and  the 
point  of  implantation,  was  found  quite  empty  of  intestinal  contents,  but 
slightly  distended  with  gas.  Implanted  end  perfectly  retained  by  sutures,  and 
slight  adhesions  between  serous  surfaces  had  already  taken  place.  Death  in 
this  case  was  the  result  of  secondary  hjemorrhage. 

Experiment  38.  Dog,  weight  thirty-five  pounds.  Divided  the  ileum  just 
above  the  ileo-caecal  region,  and  closed  both  ends  of  the  bowel.  Ileo-colostomy 
was  done  by  making  an  incision  about  an  inch  and  a  half  in  length  on  concave 
side  of  ileum,  forty-four  inches  above  the  division,  and  a  similar  slit  on  convex 
side  of  ascending  colon,  and  uniting  these  wounds  by  Czerny-Lembert  sutures, 
thus  excluding  from  the  intestinal  circulation  forty  four  inches  of  the  bowel. 
The  day  after  the  operation  the  faeces  contained  blood.  During  the  progress 
of  the  case  it  was  frequently  noted  that  the  stools  were  thin,  sometimes  liquid. 
Appetite  remained  good,  and  the  animal  was  well  nourished  at  the  time 
of  killing,  twenty-five  days  after  operation.  Abdominal  wall  well  united.  The 
omentum  and  a  few  intestinal  loops  adherent  to  inner  surface  of  wound. 
The  excluded  portion  contracted  to  more  than  one-half  of  its  usual  size, 
atrophic,  and  not  nearly  as  vascular  as  remaining  portion  of  intestinal  canal, 
the  two  blind  ends  adherent  to  each  other  and  to  adjacent  loops.  The  excluded 
portion  contained  in  its  blind  end  a  few  sharp  fragments  of  bone.  The  new 
opening  between  the  ileum  and  colon,  about  the  capacity  of  the  lumen  of  the 
ileum,  surrounded  by  a  prominent  margin  of  mucous  membrane,  which  some- 
what resembled  the  ileo-caecal  valve  to  which  still  remained  attached  about  ten 
of  the  deep  sutures.  The  coats  of  both  bowels  at  points  of  approximation 
thickened  by  inflammatory  exudation. 

Experiment  39.  Young  cat.  The  ileum  was  divided  about  thirty  inches 
above  the  ileo-csecal  region;  the  distal  end  closed  and  proximal  end  laterally 
implanted  into  the  convex  side  of  the  transverse  colon,  where  it  was  fixed  by 
a  double  row  of  sutures.  Before  implantation,  the  continuity  of  the  peritoneal 
surface  was  procured  by  drawing  the  peritoneum  with  a  fine  catgut  suture 
over  the  denuded  space  left  after  detachment  of  the  mesentery.  Although  the 
animal  partook  freely  of  food,  progressive  marasmus  set  in,  to  which  the  cat 
succumbed  eleven  days  after  the  operation.  Abdominal  wound  completely 
healed.  Union  of  implanted  ileum  with  colon  perfect.  No  peritonitis. 
Excluded  portion  empty.     Bowel  above  implantation  somewhat  dilated. 

Experiment  40.  Young,  but  fuU-grown  cat.  Physiological  exclusion  of 
two-thirds  of  the  small  intestines  and  the  entire  colon,  by  division  of  the 
small  intestines  at  the  junction  of  the  upper  with  the  middle  third.  Closure 
of  distal  end,  and  restoration  of  continuity  of  the  shortened  intestinal  tract 
by  making  a  jejuno-rectostomy.  The  implantation  was  made  into  the  upper 
portion  of  the  rectum  at  a  point  opposite  the  meso-rectum.  Previous  to 
section  and  suturing,  the  portion  of  bowel  ft)  be  excluded  was  emptied  of  its 
contents.  Animal  died  two  days  after  operation.  No  peritonitis.  Slight 
adhesions  between  the  serous  surfaces  of  rectum  and  implanted  jejunum; 
excluded  portion  empty. 


PHYSIOLOGICAL  EXCLUSION.  165 

Experiment  41.  The  entire  ileum  was  excluded,  in  a  cat,  by  dividing  the 
intestine  at  its  junction  with  the  jejunum,  closure  of  distal  end  and  making 
a  jejuno-colostomy  by  implantation  of  the  proximal  end  into  a  slit  of  the 
transverse  colon  at  a  point  opposite  the  meso-colon.  The  cat  remained  in 
good  condition  until  killed  fifteen  days  after  operation.  No  vomiting,  and 
movements  from  bowels  normal.  Abdominal  wound  completely  closed  ;  no 
peritonitis  ;  jejunum  at  point  of  implantation  firmly  united  ;  new  opening 
in  colon  the  size  of  the  lumen  of  the  ileum.  Excluded  portion  empty,  con- 
tracted and  anaemic. 

Experiment  42.  Large  mastiff.  The  small  intestine  was  divided  six  and 
a  half  feet  above  the  ileo-csecal  region,  the  distal  end  closed,  and  the  proximal 
end  implanted  into  an  incision  of  the  transverse  colon  large  enough  to  receive 
it  at  a  point  opposite  the  meso-colon.  Suturing  was  done  exclusively  with 
fine  silk.  For  three  weeks  the  dog  appeared  quite  well,  ate  well,  and  the 
discharges  from  the  bowels  were  normal.  From  this  time  the  emaciation, 
which  commenced  soon  after  the  operation  was  done,  began  to  increase 
rapidly,  the  animal  began  to  refuse  food,  and  died  of  marasmus  thirty-two 
days  after  operation.  No  peritonitis.  Excluded  portion  empty,  and  reduced 
one-half  in  size  ;  the  coats  of  the  bowels  very  much  attenuated,  and  the 
vessels  hardly  half  the  normal  size.  Only  three  feet  and  five  inches  of  the 
small  intestine  remained  for  physiological  action.  New  opening  in  colon 
sufficiently  large  to  permit  the  introduction  of  the  index  finger  as  far  as  the 
first  point.  On  slitting  open  the  colon,  the  point  of  juncture  with  the  jejunum 
upon  the  inner  surface  was  marked  by  a  slight  ridge  of  mucous  membrane, 
which  bore  a  faint  resemblance  to  the  ileo-csecal  valve. 

Remaeks.^ — For  some  reason  which  I  am  unable  to  explain 
satisfactorily,  in  animals  where  the  same  length  of  intestine  was 
physiologically  excluded,  as  in  the  resection  experiments,  the 
appetite  never  became  so  voracious,  and  the  remaining  portion  of 
intestine  did  not  undergo  the  same  degree  of  compensatory  hyper- 
trophy as  in  the  excision  experiments.  Theoretically,  two  explana- 
tions might  be  advanced  :  first,  in  shortening  the  intestinal  canal 
by  resection,  an  extensive  vascular  district  is  cut  off  by  ligation  of 
the  mesentery,  and  it  is  only  reasonable  to  assume  that  the  circula- 
tion in  the  remaining  branches  of  the  mesenteric  artery  would  be 
increased,  and  consequently  the  functional  activity  of  the  organs 
supplied  by  them  augmented  ;  second,  in  cases  of  physiological 
exclusion  by  lateral  apposition,  it  is  possible  that  at  least  some  of 
the  fluid  contents  reached  the  excluded  portion  from  which  a  certain 
amount  might  still  have  become  absorbed.  The  exclusion  was  com- 
plete or  nearly  so,  hence  we  must  conclude  from  the  post-mortem 
appearances,  that  in  nearly  every  instance,  the  excluded  portion 
presented  an  atrophic,  contracted  condition,  and  was  only  sparingly 


166  INTESTINAL  SURGERY. 

supplied  with  blood-vessels.  From  a  practical  standpoint  these 
experiments  teach  us  that  a  limited  portion  of  the  intestinal  canal 
can  be  permanently  excluded  from  the  processes  of  digestion  and 
absorption  in  proper  cases,  by  operative  measures  without  incurring 
any  risk  of  fsecal  accumulation  in  the  excluded  part.  These  experi- 
ments demonstrate  also  that  physiological  exclusion  of  a  certain 
portion  of  the  intestinal  tract  is  a  less  dangerous  operation  than 
excision,  and  that  in  certain  cases  of  intestinal  obstruction,  where 
excision  has  been  heretofore  practiced,  it  can  be  resorted  to  as  a 
substitute  for  this  operation  in  cases  where  excision  is  impracticable, 
or  where  the  pathological  conditions  which  have  caused  the  obstruc- 
tion do  not  in  themselves  constitute  an  intrinsic  source  of  immediate 
or  remote  danger  to  life.  The  post-mortem  appearances  of  the 
specimens  of  these  experiments  tend  to  prove  that  as  long  as  any 
of  the  contents  of  the  intestines  reach  the  excluded  portion,  the 
peristaltic  or  anti- peristaltic  action  in  that  part  is  effective  in  forcing 
it  back  into  the  active  current  of  the  intestinal  circulation. 

III.    Circular  Enterorrhaphy. 

During  my  experimental  work  I  became  convinced  that  circular 
enterorrhaphy  as  it  is  now  commonly  performed  is  attended  by 
three  great  sources  of  danger:  1.  Perforation  at  the  junction  not 
covered  with  peritoneum  ;  2.  Length  of  time  required  in  perform- 
ing the  operation;     3.  The  number  of  sutures  required. 

To  obviate  the  danger  of  perforation  at  the  junction  of  the 
bowel  not  covered  by  serous  membrane,  I  resorted  to  peritoneal 
suturing  before  uniting  the  bowel,  by  drawing  the  peritoneum  over 
the  denuded  space  caused  by  the  limited  detachment  of  the  mesentery, 
by  a  fine  catgut  suture  applied  near  the  free  margin  of  the  bowr-I  as 
described  before.  This  requires  but  little  time,  and  secures  for  the 
whole  circumference  of  the  bowel  a  peritoneal  covering,  so  that  after 
the  bowel  has  been  sutured  the  great  rule  inaugurated  by  Lembert 
(serosa  against  serosa)  has  been  carried  out  to  perfection.  The 
results  showed  that  this  little  modification  of  the  ordinary  method 
of  suturing  yielded  more  satisfactory  results,  and  should  therefore 
be  adopted  in  all  cases  where  circular  enterorrhaphy  is  done  with 
Czemy-Lembert  or  Lembert's  sutures.  Time  plays  an  important 
part  in  determining  the  results  of  all  operations  requiring  abdom- 
inal section ;  and  this  is  especially  true  in  all  operations  for  intestinal 


CIRCULAR  ENTERORRHAPHY.  167 

obstruction,  as  this  class  of  patients  is  usually  greatly  exhausted 
before  consent  to  an  operation  can  be  obtained.  With  a  patient 
exhausted  from  an  acute  attack  of  obstruction  of  the  bowels,  it 
becomes  exceedingly  important  to  consume  as  little  time  as  possible 
in  the  operation,  as  the  shock  incident  to  a  long  operation  may  itself 
determine  a  fatal  result.  Even  after  I  had  acquired  a  fair  degree 
of  manual  dexterity  in  suturing  the  bowel,  I  seldom  spent  less  than 
an  hour  in  making  a  circular  enterorrhaphy  with  a  double  row  of 
sutures.  In  opening  the  abdomen  for  intestinal  obstruction,  a  consid- 
erable length  of  time  is  usually  spent  in  finding  the  obstruction;  and 
when  this  is  found  and  the  patient  manifests  symptoms  of  collapse, 
a  radical  operation,  which  for  its  performance  requires  an  hour  or 
more,  is  often  abandoned  and  the  operation  finished  by  making  an 
artificial  anus,  which  at  the  present  time  must  be  looked  upon  as  a 
reproach  upon  good  surgery. 

The  last  objection  to  the  Czerny-Lembert  method  of  suturing 
requires  no  argument.  Any  surgeon  who  hastily  transfixes  the  bowel 
with  a  needle  from  thirty  to  forty  times  in  applying  the  Lembert 
suture  is  liable  to  perforate  the  whole  thickness  of  its  walls  once  or 
more;  and  if  silk  is  used  as  suturing  material,  the  puncture  may 
become  the  seat  of  a  perforation,  and  the  direct  cause  of  a  fatal  peri- 
tonitis. This  is  more  particularly  the  case  in  operating  on  the  bowel 
in  cases  of  intestinal  obstruction,  as  under  such  circumstances  the 
walls  of  the  bowel  have  become  greatly  attenuated  from  overdisten- 
tion,  and  consequently  more  liable  to  become  perforated  by  the 
needle.  But  the  use  of  so  many  sutures,  from  thirty  to  forty  as 
recommended,  brings  with  it  another  source  of  danger — gangrene 
of  the  inverted  margin  of  the  bowel.  The  second  row  of  sutures 
applied  in  such  close  proximity  must  materially  affect  the  blood 
supply  to  the  inverted  margin  of  the  bowel,  which  in  some  instances 
must  terminate  in  gangrene.  Such  a  result  is  the  more  likely  to 
ensue  as  the  inner  surface  of  the  bowel  is  exposed  to  all  dangers 
incident  to  infection  from  the  intestinal  canal;  in  other  words,  an 
aseptic  condition  for  one  side  of  the  wound  cannot  be  secured,  con- 
sequently the  gangrene  is  of  a  septic  character,  which  is  prone  to 
extend  beyond  the  primary  cause  which  produced  it. 

To  obviate  some  of  these  dangers  I  experimented  with  a  modifi- 
cation of  Jobert's  invagination  suture.  According  to  Madelung,  the 
ingenious  method  of  circular  suturing  devised  by  Jobert  was  practiced 


168  INTESTINAL  SURGERY. 

only  in  four  cases,  and  two  of  the  patients  are  known  to  have  recov- 
ered. A  number  of  years  ago,  I  was  forced  to  resort  to  resection  of 
a  part  of  the  small  intestine  in  a  very  complicated  case  of  ovariotomy 
and  resorted  to  this  method,  and  although  the  patient  died  forty-eight 
hours  after  the  operation  from  causes  outside  of  this  complication, 
the  bowel  was  found  permeable  and  quite  firmly  united,  and  had  the 
patient  lived  I  have  no  doubt  the  result  of  the  resection  and  sutur- 
ing would  have  been  satisfactory.  In  Jobert's  method  the  invagina- 
tion sutures  must  be  looked  upon  as  a  source  of  danger,  as  they 
were  made  to  traverse  the  entire  thickness  of  the  wall  of  the  bowel, 
and  the  material  used  was  silk.  It  has  been  claimed  that  in  this 
method  the  invaginated  portion  of  the  bowel  becomes  gangrenous  as 
in  cases  of  invagination  from  pathological  causes.  This  claim  has 
arisen  from  a  theoretical,  and  not  from  an  experimental  standpoint. 
In  cases  of  invagination  the  intussusceptum  carries  with  it  the 
mesenteric  vessels  intact  in  the  form  of  an  arch,  which  by  constriction 
at  the  neck  of  the  intussuscipiens  is  prone  to  become  strangulated, 
an  event  which  is  followed  by  cedema  and  inflammatory  swelling  of 
the  invaginated  portion,  which  rapidly  tends  to  complete  venous 
stasis  and  gangrene.  In  circular  suturing  by  Jobert's  method  the 
intussusceptum  has  no  vascular  connection  with  the  intussuscipiens. 
The  vascular  arch  is  interrupted  and  consequently  the  danger  arising 
from  venous  obstruction  is  almost  completely  obviated.  My  experi- 
ments will  show  that  gangrene  of  the  invaginated  portion  as  a  rule 
does  not  occur.  My  modification  of  Jobert's  method  consists 
essentially  in  the  use  of  a  thin  elastic  rubber  ring  for  lining  the 
intussusceptum  to  prevent  ectropium  of  the  mucous  membrane,  to 
protect  the  mucous  membrane  of  the  bowel  against  injurious  pressure 
from  the  suture,  to  keep  the  lumen  of  the  bowel  patent  during  the 
inflammatory  stage,  and  to  assist  in  maintaining  coaptation  of  the 
serous  surfaces,  and  finally  the  substitution  of  catgut  for  silk  as 
invagination  sutures. 

My  method  of  proceeding  is  as  follows:  The  upper  end  of 
the  bowel  which  is  to  become  the  intussusceptum  is  lined  with  a 
soft  pliable  rubber  ring  made  of  a  rubber  band,  transformed  into 
a  ring  by  fastening  the  ends  together  with  two  catgut  sutures. 
This  ring  must  be  the  length  of  the  intussusceptum,  from  one-third 
to  half  an  inch;  the  lower  margin  is  stitched  by  a  continuous  catgut 
suture  to  the  lower  end  of  the  bowel  which  effectually  prevents  the 


CIRCULAR  ENTERORRHAPHY.  169 

biilging  of  the  mucous  membrane,  a  condition  which  is  always 
difficult  to  overcome  in  circular  suturing.  After  the  ring  is  fastened 
in  its  place  the  end  of  the  bowel  presents  a  tapering  appearance 
which  materially  facilitates  the  process  of  invagination.  Two  well- 
prepared  fine  juniper  catgut  sutures  are  threaded  each  with  two 
needles.  The  needles  are  passed  from  within  outwards,  transfix- 
ing the  upper  portion  of  the  rubber  ring  and  the  entire  thickness 
of  the  wall  of  the  bowel  and  always  equidistant  from  each  other; 
the  first  suture  being  passed  in  such  a  manner  that  each  needle  is 
brought  out  a  short  distance  from  the  mesenteric  attachment,  and 
the  second  suture  on  the  opposite  convex  side  of  the  bowel.  During 
this  time  an  assistant  keeps  the  opposite  end  of  the  bowel  compressed 
to  prevent  contraction  and  bulging  of  the  mucous  membrane.  The 
needles  next  are  passed  through  the  peritoneal,  muscular  and  con- 
nective tissue  coats  at  corresponding  points  about  one-third  of  an 
inch  from  the  margins  of  the  opposite  end  of  the  bowel,  and  when 
all  the  needles  have  been  passed,  an  assistant  makes  equal  traction 
on  the  four  strings,  and  the  operator  assists  the  invagination  by 
turning  in  the  margins  of  the  lower  end  evenly  with  a  director,  and 
by  gently  pushing  the  rubber  ring  completely  into  the  intussus- 
cipiens.  The  invagination  accurately  made,  the  two  catgut  sutures 
are  tied  only  with  sufficient  firmness  to  prevent  disinvagination 
should  violent  peristalsis  follow  the  operation.  This  is  their  only 
function. 

The  invagination  itself  efFects  accurate,  almost  hermetical  seal- 
ing of  the  visceral  wound.  The  intestinal  contents  pass  freely 
through  the  lumen  of  the  rubber  ring  from  above  downwards,  and 
escape  from  below  is  impossible,  as  the  free  end  of  the  intussuscipiens 
secures  accurate  valvular  closure.  After  a  few  days  the  rubber  ring 
becomes  detached,  and  by  giving  way  of  the  catgut  sutures  is  again 
transformed  into  a  flat  band,  which  readily  passes  ofP  with  the  dis- 
charges through  the  bowels.  The  invagination  sutures  of  catgut  are 
gradually  removed  by  substitution  on  the  part  of  the  tissues,  hence  the 
punctures  in  the  bowel  remain  closed  either  by  the  catgut  or  by  the 
products  of  local  tissue-proliferation;  and  thus  extravasation  is  pre- 
vented. In  my  first  experiments  I  used  three  invagination  sutures, 
but  found  by  experience  that  two  are  just  as  efficient  in  making  and 
retaining  the  invagination.  No  superficial  or  peritoneal  sutures  were 
used  in  any  of  the  cases,  sole  reliance  being  placed  upon  the  invagi- 


170  INTESTINAL  SURGERY, 

nation  to  maintain  approximation  and  coaptation.  The  mesenteric 
attachment,  both  of  the  intussusceptum  and  intussuscipiens,  was 
separated  only  a  few  lines  to  enable  invagination  without  too  much 
narrowing  of  the  lumen  of  the  intussuscipiens. 

Experiment  43.  Dog,  weight  fifteen  pounds.  Three  invagination  sutures 
were  used.  The  ileum  was  cut  completely  across  at  a  point  about  three  feet 
above  the  ileo-caecal  region.  Depth  of  invagination  one  inch.  For  two  days 
after  operation  a  slight  rise  in  temperature;  no  symptoms  of  obstruction 
during  the  whole  time.  Animal  in  good  condition  when  killed  two  weeks  after 
operation.  Omentum  adherent  at  point  of  operation  as  well  as  on  adjacent 
loop  of  intestine.  Union  between  intussusceptum  and  intussuscipiens  firm, 
no  signs  of  gangrene.  Narrowest  portion  of  lumen  of  bowel  was  large  enough 
to  pass  the  little  finger  to  second  joint.  An  enterolith  composed  of  fragments 
of  wood,  bone,  etc.,  in  the  centre  of  which  the  straight  rubber  band  which  had 
been  the  rubber  ring,  was  found  just  above  the  seat  of  operation.  No  disten- 
tion of  the  bowel  above  this  point.  Bowel  considerably  flexed  at  seat  of 
invagination,  this  condition  being  evidently  brought  about  by  inflammatory 
adhesions. 

Experiment  44.  Dog,  weight  twenty  pounds.  Section  of  bowel  and 
invagination  with  rubber  ring  the  same  as  in  the  foregoing  experiment.  In 
subsequent  history  no  mention  is  made  of  any  symptom  of  obstruction,  but 
for  the  last  few  weeks  it  was  noticed  that  the  dog  began  to  emaciate.  He  died 
suddenly  eighty-one  days  after  the  operation.  Diarrhoea  was  a  prominent 
symptom  toward  the  last.  No  adhesions  and  no  peritonitis.  An  enormous 
enterolith  composed  of  all  kinds  of  crude  material,  and  again  holding  in  its 
centre  the  rubber  band,  was  found  just  above  the  invagination.  Bowel  at  this 
place  considerably  dilated.  Intussusceptum  firmly  adherent,  a  false  passage 
admitting  the  tip  of  the  little  finger  had  been  made  on  one  side  between  it  and 
the  intussuscipiens.  Death  in  this  case  was  evidently  produced  by  the  entero- 
lith. In  this,  as  in  the  last  case,  the  invagination  was  made  at  least  an  inch 
in  length,  and  the  collection  around  the  detached  rubber  ring  of  the  crude, 
indigestible  material,  which  the  dog  must  have  eaten  in  large  quantities,  gave 
rise  to  the  enterolith.  The  wall  of  the  bowel  surrounding  the  foreign  body 
was  not  only  dilated,  but  also  greatly  thickened.  It  is  a  well  known  fact  that 
even  a  moderate  degree  of  stenosis  of  the  bowel  in  dogs  is  liable  to  give  rise 
to  the  formation  of  an  enterolith,  as  the  crude  material  which  these  animals 
swallow  becomes  arrested,  and  by  constant  accretions  of  the  same  kind  of 
material,  the  enterolith  forms  and  continues  to  increase  in  size,  until  its  pres- 
ence causes  catarrhal  inflammation  and  finally  intestinal  obstruction. 

It  is  quite  possible  that  the  lower  end  of  the  intussusceptum  became 
impermeable  during  the  inflammatory  stage,  and  that  the  false  passage  was 
formed  on  this  account  by  perforation  on  one  side  of  the  intussusceptum,  an 
accident  which  was  plainly  traceable  to  too  deep  invagination. 

Experiment  45.  Dog,  weight  forty  pounds.  This  experiment  is  interest- 
ing only  from  the  fact  that  it  shows  that  it  is  possible  to  make  a  mistake  in 


NOTHNAGEVS   TEST.  171 

the  direction  of  the  invagination,  even  after  the  operation  has  determined 
with  accnracy  which  is  the  ascending  and  descending  end  of  the  gut,  and  to 
show  the  disastrous  consequences  which  must  necessarily  follow  such  a  techni- 
cal mistake.  The  invagination  was  made  in  the  usual  manner  with  rubber 
ring  and  three  catgut  sutures.  The  animal  appeared  to  be  quite  ill  the  day 
following  the  operation,  and  on  the  next  day  the  thermometer  showed  a  rise 
in  temperature  to  104.2°F.  On  the  third  day  the  dog  died  with  weU  marked 
symptoms  of  perforative  peritonitis.  Recent  peritonitis  with  some  aggluti- 
nations of  intestines.  Considerable  quantity  of  sero-sanguinolent  fluid  in  the 
peritoneal  cavity.  To  my  utter  astonishment,  I  found  that  an  ascending 
invagination  had  been  made.  Circular  gangrene  of  intussusceptum  and  com- 
plete separation  of  ends  was  found.  The  rubber  ring  remained  in  situ  still 
attached  to  the  intussuscipiens  by  the  catgut  sutures,  which  had  become  some- 
what softened.  The  invagination  had  decreased  considerably  by  the  traction 
caused  by  the  peristalsis  and  by  the  pressure  of  the  intestinal  contents  from 
above  the  obstruction,  and  the  extensive  gangrene  of  the  bowel  was  undoubt- 
edly determined  to  a  great  extent  by  these  causes. 

Experiment  46.  This  experiment  illustrates  another  source  of  danger 
due  to  faulty  technique.  Medium-sized  dog.  Circular  enterorrhaphy  was  done 
with  the  rubber  ring  two  feet  above  the  ileo-csecal  valve.  In  making  the  invagi- 
nation it  was  noticed  that  the  ring  was  too  large,  as  it  was  seen  that  it  caused 
too  much  pressure.  Thinking  that  the  parts  might  adapt  themselves  to  this 
pressure,  the  bowel  was  replaced  and  the  abdominal  wound  closed.  The  dog 
died  thirty-six  hours  after  the  operation.  Abdominal  wound  not  united; 
omentum  and  intestines  adherent  to  each  other,  and  at  point  of  operation. 
The  circumscribed  gangrene  of  the  intussuscipiens  was  evidently  entirely  due 
to  pressure  on  the  part  of  the  rubber  ring.  The  intussuscipiens  was  much 
swollen,  a  condition  which  materially  aggravated  the  pressure  caused  by  the 
rubber  ring.  With  the  following  experiment  two  new  departures  were  inaugu- 
rated, viz.:  Instead  of  three  invagination  sutures  only  two  were  used,  a  change 
which  still  further  shortened  the  time  for  performing  the  operation,  and  Noth- 
nagel's  test  was  employed  to  determine  the  direction  in  which  the  invagination 
should  be  done.  In  all  of  the  remaining  experiments  of  circular  enterorrhaphy 
which  were  made,  only  two  catgut  sutures  were  used.  Until  this  time  it  was 
necessary  to  find  one  of  the  extremities  of  the  small  intestines  for  the  pur- 
pose of  determining  which  was  the  afferent  and  which  the  efferent  end  of  the 
tube,  so  as  to  make  the  invagination  in  the  right  direction;  a  procedure  which 
often  required  considerable  time,  and  brought  additional  risk  by  increasing 
the  shock  of  the  operation  and  the  danger  of  traumatic  infection. 

I.    Nothnagers  Test. 

In  experimenting  upon  animals  for  the  purpose  of  studying  the 
functions  of  the  intestinal  canal  in  health  and  disease,  Nothnagel 
made  the  discovery  that  when  the  salts  of  potash  are  brought  in 
contact  with  the  serous  surface  of  the  bowel,  circular  constriction 


172  INTESTINAL  SURGERY. 

takes  place,  and  when  the  peritoneal  surface  is  touched  with  a 
crystal  of  common  salt,  ascending  peristalsis  is  produced.  The  sodic 
chloride  test  I  applied  in  sixteen  cases,  and  found  Nothnagel's 
observations  corroborated  in  fifteen  cases,  by  subsequent  anatomical 
examination.  In  the  remaining  case  where  a  wrong  conclusion  was 
drawn,  the  error  might  have  been  due  to  a  faulty  observation,  or  else 
the  observation  was  not  continued  for  a  sufficient  length  of  time.  If, 
in  the  human  subject,  these  observations  could  be  verified,  it  would 
be  of  great  practical  importance  to  surgeons  in  operations  on  the 
intestinal  canal  whenever  it  becomes  necessary  to  determine  which 
is  the  ascending  or  descending  part  of  the  bowel. 

Experiment  47.  Dog,  weight  thirty  pounds.  Circular  section  of  ileum 
and  immediate  enterorrhaphy  by  invagination  with  rubber  ring  and  two 
catgut  sutures.  Intussusceptum  invaginated  not  more  that  a  quarter  of  an 
inch.  A  few  days  after  the  operation  stools  mixed  with  blood,  no  other 
unfavorable  symptoms.  Animal  killed  fourteen  days  after  operation.  Wound 
united  firmly.  A  number  of  omental  and  intestinal  adhesions.  A  small 
abscess  in  mesentery  at  point  of  operation.  No  obstruction  of  any  kind.  On 
opening  the  bowel  the  walls  at  site  of  operation  were  very  thick,  correspond- 
ing to  the  three  intestinal  coats,  which  had  become  considerably  attenuated. 
The  inner  surf  ace  showed  the  point  of  junction  of  the  intussusceptum  with  the 
intussuscipiens  in  the  shape  of  a  circular  ring  of  mucous  membrane.  The 
most  contracted  portion  was  large  enough  to  admit  the  little  finger. 

Experiment  48.  Dog,  weight  fifteen  pounds.  Section  of  ileum  and 
circular  enterorrhaphy  with  rubber  ring  and  two  catgut  sutures.  Depth  of 
invagination  one-third  of  an  inch.  No  unfavorable  symptoms  after  operation. 
Animal  killed  after  seven  days.  Wound  completely  united.  Firm  union  of 
visceral  wound;  no  gangrene  of  intussusceptum.  Rubber  ring  retained  in  situ 
by  catgut  sutures,  which  were  easily  torn.  Upper  end  of  rubber  ring  matted 
with  hair.  No  obstruction.  Lumen  of  bowel  somewhat  contracted  by  a 
circular  ridge  of  mucous  membrane,  which  indicated  the  junction  of  the  two 
invaginated  ends  of  the  bowel. 

2.     Transplantation  of  Omental  Flap. 

In  almost  all  post-mortem  examinations  of  specimens  from  oper- 
ations on  the  intestines,  I  observed  that  the  omemtum  was  adherent 
over  a  greater  or  less  surface  at  the  seat  of  suturing.  I  also  observed 
that  perforations  never  occurred  where  this  additional  protection 
to  the  peritoneal  cavity  had  formed.  To  anticipate  nature  in 
protecting  the  peritoneal  cavity  in  this  manner,  I  commenced  to 
transplant  an  omental  flap  about  an  inch  in  width  and  sufficiently 
long  to  reach  around  the  bowel,  over  the  neck  of  the  intussuscipiens. 


TRANSPLANTATION  OF  OMENTAL  FLAP.  173 

where  it  was  fastened  on  the  mesenteric  side  by  two  catgut  sutures. 
The  flap  was  taken  either  from  the  margin  of  the  omentum  or  from 
its  middle,  care  being  taken  to  take  some  portions  supplied  with  a 
vessel  of  considerable  size.  Its  base  was  left  attached  to  the 
omentum;  all  bleeding  points  were  carefully  tied  with  catgut  liga- 
tures. The  two  catgut  stitches  used  for  its  fixation  were  passed  twice 
through  the  flap,  its  base  and  free  end  and  the  mesentery,  in  such  a 
way  that  when  tied  the  direction  of  the  suture  corresponded  to  the 
course  of  the  mesenteric  vessel,  so  that  after  tying  they  would  not 
interfere  with  the  vascular  supply  of  the  bowel.  When  the  flap  was 
taken  from  the  middle  of  the  omentum,  the  lateral  halves  were  united 
with  one  or  two  catgut  sutures  before  closing  the  abdominal  wound. 

Experiment  49.  Dog,  weight  forty  pounds.  Ileum  divided  eighteen 
inches  above  ileo-caacal  region,  and  the  ends  united  by  invagination  with 
rubber  ring,  and  two  catgut  sutures.  Transplantation  of  omental  flap  one 
inch  in  width  around  the  whole  circumference  of  the  bowel  over  neck  of  intus- 
suscipiens,  fixation  with  two  catgut  sutures  on  mesenteric  side.  Invagination 
one-third  of  an  inch  in  depth.  Animal  killed  two  weeks  after  operation. 
Abdominal  wound  perfectly  healed.  Omental  flap  firmly  adherent  to  bowel 
over  neck  of  intussuscipiens.  Bowel  at  seat  of  operation  much  thickened; 
rubber  ring  gone;  lumen  of  bowel  at  its  most  contracted  point  large  enough 
for  the  passage  of  the  little  finger. 

Experiment  50.  Dog,  weight  twenty  pounds.  Complete  division  of  ileum 
and  immediate  union  of  divided  ends  by  invagination  with  rubber  ring  and 
two  catgut  sutures.  Transplantation  of  omental  flap  two  inches  in  width 
over  the  neck  of  the  intussuscipiens.  On  third  day  stools  mixed  with  blood. 
Died  on  the  fifth  day.  Wound  not  united;  omental  flap  firmly  adherent  except 
at  a  small  point  on  the  mesenteric  side  where  a  minute  perforation  had  taken 
place  from  circumscribed  gangrene  of  the  intussusceptum.  Rubber  ring  only 
loosely  held  by  one  of  the  sutures.  Lumen  in  invaginated  portion  >  quite 
narrow,  but  permeable. 

ExpeHrnent  51.  Dog,  weight  fifteen  pounds.  Complete  section  of  ileum 
and  union  of  divided  ends  by  invagination.  The  rubber  ring  was  only  one- 
third  of  an  inch  wide,  while  formerly  none  were  used  less  than  half  an  inch 
in  width.  Neck  of  intussuscipiens  protected  by  an  omental  flap  two  inches 
wide.  The  dog  remained  perfectly  well,  and  was  killed  twenty-five  days  after 
operation.  Abdominal  wound  completely  healed,  covered  on  the  inner  side 
by  adherent  omentum.  Rubber  ring  gone.  Lumen  of  bowel  at  most  con- 
tracted point  readily  admits  the  little  finger.  No  signs  of  obstruction. 
Omental  flap  adherent  throughout. 

Experiment  52.  Dog,  weight  twenty-two  pounds.  Division  of  ileum  and 
suturing  in  usual  manner  by  invagination  with  rubber  ring  and  two  catgut 
sutures;  transplantation  of  omental  flap.  The  dog  remained  perfectly  well 
and  was  killed  twenty-three  days  after  operation.     A  number  of  intestinal 


174  INTESTINAL  SURGERY. 

adhesions  had  produced  several  flexions.  Point  of  operation  four  feet  above 
the  ileo-caecal  region.  Omental  flap  firmly  adherent  to  bowel  throughout. 
Rubber  ring  gone.  Lumen  of  bowel  in  invaginated  portion  quite  large. 
Thb  invaginated  portion  so  atrophic  and  retracted  that  it  appeared  in  the 
shape  of  a  firm  ring  and  was  indicated  in  the  interior  by  a  circular  jjromi- 
nence  of  the  mucous  membrane.     No  evidence  of  obstruction. 

Experiment  53.  Dog,  weight  fifteen  pounds.  Complete  division  of  the 
ileum  and  reunion  of  ends  by  invagination.  Transplantation  of  omental 
flap  two  inches  in  width  over  neck  of  intussuscipiens,  two  catgut  fixation 
sutures.  Second  day  after  operation  stools  bloody.  After  this  time  all  func- 
tions normal.  Animal  killed  forty-four  days  after  operation.  Point  of  opera- 
tion four  feet  below  the  pylorus.  The  invaginated  portion  atrophied  and 
retracted  to  such  an  extent  that  the  bowel  at  this  point  only  presented  a  thick- 
ened ring  with  its  lumen  but  slightly  narrowed  by  a  circular  ridge  of  mucous 
membrane.      Omental  flap  firmly  adherent  all  around  and  greatly  atrophied. 

Remarks. — In  circular  enterorrhaphy,  as  in  cases  of  intestinal 
wounds  of  any  kind,  the  ideal  of  any  operation  should  be  to  bring 
in  continuous,  uninterrupted  apposition  a  large  surface  of  serous 
membrane,  without,  at  the  same  time,  interfering  with  the  vascular 
supply  of  the  parts  which  it  is  intended  to  bring  together  for  perma- 
nent union  by  cicatrization.  If  in  employing  the  Czerny-Lembert 
sutures  more  than  a  few  lines  of  the  margins  of  the  bowel  are 
inverted  and  included  between  the  two  rows  of  sutures,  there  is 
great  danger  of  causing  primary  traumatic  stenosis  by  the  project- 
ing circular  ring  in  the  lumen  of  the  bowel.  The  narrowing  of  the 
lumen  of  the  bowel  must  be  as  great,  if  not  greater,  than  after 
invagination.  That  the  second  row  of  sutures  has  often  been  the 
cause  of  gangrene  of  the  inverted  margin  of  the  bowel  would  not 
be  difficult  to  prove  by  many  post-mortem  records  and  specimens. 
By  invaginating  to  the  depth  of  a  quarter  or  third  of  an  inch,  accu- 
rate coaptation  is  secured  of  the  corresponding  serous  surfaces 
between  the  intussusceptum  and  intussuscipiens,  which  is  made 
more  secure  and  efPective  by  the  elastic  pressure  exerted  by  the  rub- 
ber ring.  This  method  of  coaptation  furnishes  a  large  peritoneal 
surface  of  peritoneum  for  immediate  union  by  cicatrization. 

With  perhaps  one  exception,  all  of  my  experiments  have  shown 
that  when  catgut  was  used  for  invagination  sutures  none  of  the  fail- 
ures were  attributable  to  their  presence.  On  the  inner  side  of  the 
bowel  the  rubber  ring  is  drawn  against  the  puncture,  and  would  thus 
furnish  a  mechanical  protection  against  the  escape  of  fluids  along 
these  minute  canals  ;  besides,  the  swelling  of  the  catgut  where  it 


CIRCULAR   ENTERORRHAPHY.  175 

becomes  softened  by  the  fluids  of  the  tissues,  would  most  effectually 
plug  the  punctures  until  a  permanent  plug  is  furnished  by  the  gran- 
ulations, which  in  time  completely  remove  the  catgut  by  substitution 
and  close  the  punctures  permanently  by  a  minute  cicatrix.  One  great 
advantage  of  the  rubber  ring  consists  in  its  furnishing  absolute 
protection  to  the  bowel  against  pressure  by  the  invagination  sutures 
during  the  invagination,  and  subsequent  traction  from  peristaltic 
contraction  should  the  latter  cause  tension  of  the  sutures,  an  occur- 
rence which  is  not  likely  to  arise  if  the  invagination  has  been 
properly  done.  A  circular  enterorrhaphy  as  described  above  can  be 
done  in  fifteen  minutes,  which  certainly  compares  very  favorably 
with  any  other  procedure,  as  far  as  time  is  concerned.  In  the 
description  of  a  number  of  the  specimens,' it  has  been  distinctly 
stated  that  the  injurious  results  followed  the  stenosis  caused  by  the 
invagination,  and  this  might  be  urged  as  an  argument  against  the 
safety  and  applicability  of  the  operation. 

As  compared  with  the  human  subject  the  dog  is  an  unfavorable 
animal  for  circular  enterorrhaphy  by  invagination.  In  the  first  place, 
the  walls  of  the  bowel  are  much  thicker  in  proportion  to  its  lumen 
than  in  man,  a  condition  which  of  necessity  seriously  affects  the 
lumen  of  the  intussusceptum.  Again,  the  dogs  were  allowed  to  eat 
what  they  desired  before  and  after  the  operation,  and  the  quantity 
was  not  limited;  consequently  a  great  deal  of  indigestible  substances, 
often  of  the  coarsest  kind,  as  straw,  fragments  of  wood,  or  bone, 
hair,  etc.,  found  their  way  into  the  intestinal  canal,  and  in  a  number 
of  cases  were  arrested  at  the  point  of  narrowing  in  the  bowel,  where 
they  gave  rise  to  the  formation  of  an  enterolith.  In  one  instance 
death  resulted  clearly  from  intestinal  obstruction  from  such  a  cause. 
In  men  the  coats  of  the  bowel  being  thinner,  and  the  lumen  corre- 
spondingly larger,  invagination  is  done  with  greater  ease,  and  the 
danger  from  stenosis  could  hardly  come  into  question,  as  the  fluid 
contents  of  the  small  intestines  would  pass  readily  through  the 
rubber  tube.  Some  of  the  older  specimens  prove  that  the  traumatic 
stenosis  caused  by  the  invagination  gradually  diminishes  by  atrophy 
of  the  invaginated  portions,  which  finally  only  appear  as  a  promi- 
nent ridge  of  mucous  membrane  on  the  inner  surface  of  the  bowel, 
the  remaining  coats  having  completely  or  nearly  disappeared  by 
retrograde  metamoi'phosis  and  absorption.  In  the  healing  of  all 
wounds  one  important  condition  for  an  ideal  result  is  rest.     The 


176  INTESTINAL  SURGERY. 

rubber  ring  in  the  intussusceptum  secures  this  important  condition 
for  the  invaginated  portion,  as  the  elastic  pressure  must  overcome 
peristaltic  action  and  secure  for  this  segment  of  the  bowel,  as  near 
as  possible,  absolute  physiological  rest.  The  danger  of  stenosis 
after  invagination  is  greatest  as  soon  as  inflammatory  swelling 
makes  its  appearance,  a  day  or  two  after  the  operation,  and  the  rub- 
ber ring  is  again  in  the  right  place  to  prevent  any  undue  swelling 
by  affording  a  gentle  support  for  the  invaginated  portion,  which 
cannot  fail  in  preventing  undue  venous  engorgement  and  oedema, 
which  would  otherwise  follow  the  invagination.  It  serves  both  the 
purpose  of  a  splint  and  an  elastic  bandage.  After  union  of  the 
bowel  by  invagination  with  a  rubber  ring  peritoneal  sutures  are 
superfluous,  as  the  invagination  itself  most  effectually  prevents  any 
escape  of  intestinal  contents  by  the  valvular  action  of  the  invaginated 
portion ;  at  the  same  time  the  serous  surfaces  are  kept  in  perma- 
nent and  uninterrupted  contact  by  the  elastic  pressure  on  the  part 
of  the  rubber  ring. 

Although  the  experiments  have  demonstrated  the  safety  of  the 
catgut  invagination  sutures  in  operating  upon  dogs,  the  same 
innocuity  might  not  attend  operations  after  intestinal  resections  for 
obstruction,  as  in  such  cases  the  coats  of  the  bowel  are  almost  with- 
out exception  very  much  attenuated,  and  consequently  the  danger 
of  extravasation  along  the  needle  punctures  would  be  increased. 
Very  recent  trials  have  satisfied  me  that  invagination  after  circular 
resection  can  be  done  with  the  rubber  ring  with  facility,  and  probably 
greater  safety,  by  dispensing  with  the  invagination  sutures  and 
adopting  the  following  plan:  The  lower  end  of  the  intussusceptum 
is  lined  with  a  soft  rubber  ring  about  one-quarter  to  one-third  of  an 
inch  in  width,  and  its  lumen  of  sufficient  size  to  afford  free  transit 
to  the  intestinal  contents.  The  lower  margin  of  the  ring  is  stitched 
to  the  end  of  the  intussusceptum  by  a  continued  fine  catgut  suture. 
The  ends  of  the  bowel  are  now  brought  in  contact  and  fastened 
together  with  four  catgut  sutures  which  are  placed  equidistant  from 
each  other.  Invagination  is  now  made  by  gently  pushing  the  ends 
of  the  bowel  in  opposite  directions,  being  careful  to  push  the  ring 
sufficiently  deep  so  that  its  upper  margin  is  grasped  by  the  neck  of 
the  intussuscipiens.  A  few  superficial  sutures  are  applied  simply 
for  the  purpose  of  preventing  disinvagination  ;  the  four  catgut 
sutures  act  as  invagination  sutures,  and  at  the  same  time  prevent 


INTESTINAL   ANASTOMOSIS.  177 

ectropium  of  the  mucous  membrane  of  the  lower  end  of  the  bowel 
during  and  after  invagination.  With  proper  facilities  and  good 
assistance,  a  circular  enterorrhaphy  can  be  made  in  this  manner 
without  using  invagination  sutures,  in  ten  minutes;  and  by  using  not 
more  than  four  retention  sutures,  the  blood  supply  to  the  inverted 
portions  is  not  impaired,  and  at  the  same  time  the  two  ends  of  the 
bowel  have  been  joined  together  by  a  large  surface  of  peritoneum, 
which  is  held  in  accurate  contact  for  rapid  union  by  granulation 
and  cicatrization. 

The  advantages  that  are  derived  from  covering  a  sutured  intes- 
tinal wound  by  an  omental  flap  are  self-evident.  The  procedure  is 
simply  an  imitation  of  nature's  process  in  protecting  the  perito- 
neal cavity  against  perforation,  and  in  hastening  the  healing  of  the 
visceral  wound.  An  adherent  omentum  secures  rest  for  the  part  to 
which  it  has  become  attached.  As  the  omental  flap  becomes  firmly 
adherent  before  definitive  healing  of  the  visceral  wound  has  taken 
place,  it  furnishes  additional  protection,  and  in  the  event  of  a  small 
perforation  it  guards  against  perforative  peritonitis  by  mechanically 
preventing  the  entrance  of  pus  into  the  peritoneal  cavity.  Should 
pus  reach  the  omental  flap  after  it  has  become  firmly  adherent  it  is 
not  very  probable  that  perforation  would  take  place  through  the 
two  layers  of  peritoneum  furnished  by  the  adherent  omental  flap,  and 
the  subsequent  healing  of  the  perforation  of  the  bowel  would  be 
most  likely  to  take  place.  I  shall  again  refer  to  this  subject  under 
the  head  of  "Omental  Grafting." 

IT.    Intestinal  Anastomosis. 

By  an  intestinal  anastomosis  we  understand  a  condition  of  the 
intestinal  canal  where  on  account  of  an  obstruction  or  complete 
occlusion,  the  intestinal  contents  are  directed  into  a  segment  of  the 
bowel  below  the  seat  of  obstruction  or  occlusion,  through  a  fistulous 
opening  between  the  bowel  above  and  below  the  seat  of  partial  or 
complete  occlusion.  The  idea  of  establishing  such  a  communication 
between  the  bowel  above  and  below  the  seat  of  obstruction  originated 
with  Maisonneuve,  who,  without  testing  the  new  procedure  first  on 
animals,  operated  on  two  cases,  but  as  the  result  in  each  case  was 
fatal,  he  seems  to  have  become  discouraged  and  abandoned  the 
operation,  and  never  published  the  communication  on  this  subject 
which  he  had  in  preparation.      In  the  Surgical  Society  of  Paris,  his 

12 


178  INTESTINAL  SURGERY. 

proposition  met  with  violent  opposition  from  his  contemporaries,  who 
argued  that  the  excluded  portion  of  the  intestine  would  become  the 
seat  of  faecal  accumulation,  which,  even  if  the  operation  were  a 
success,  would  subsequently  destroy  the  life  of  the  patient.  The 
subject  was  revived  in  1863  by  Hacken,  who  under  the  directions  of 
Adelmann  made  some  experiments  on  dogs.  For  a  long  time  the 
operation  was  completely  forgotten  until  E.  Hahn,  of  Berlin,  very 
recently  alluded  to  it  again  in  commenting  on  his  two  cases  of 
excision  of  the  colon  where  circular  enterorrhaphy  could  not  be 
performed,  and  where  an  artificial  anus  was  established.  Both 
patients  recovered  from  the  operation,  but  all  attempts  to  close  the 
preternatural  opening  proved  futile. 

The  results  of  my  experiments  have  shown  conclusively  that  the 
fear  of  accumulation  of  f seces  in  the  excluded  portion  of  the  intestine, 
that  is,  the  intervening  portion  containing  the  seat  of  obstruction 
and  extending  on  each  side  as  far  as  the  new  opening  by  which  the 
anastomosis  has  been  established,  is  unfounded.  If  this  objection 
can  be  laid  aside,  it  becomes  evident  that  the  operation  of  establish- 
ing intestinal  anastomosis  has  a  great  future,  and  will  soon  become 
an  established  procedure  in  the  treatment  of  intestinal  obstruction, 
and  as  a  substitute  for  circular  suturing  in  some  forms  of  injuries  of 
the  intestines,  which  require  excision.  When  I  first  made  my  experi- 
ments for  establishing  intestinal  anastomosis,  I  made  the  operation 
by  making  an  incision  an  inch  and  a  half  to  two  inches  in  length 
through  the  convex  surface  of  each  bowel,  and  sutured  the  wounds 
together  by  Czerny-Lembert  sutures  the  same  as  in  making  a  circular 
enterorrhaphy.  The  results  soon  showed  that  the  operation  was 
attended  by  the  same  dangers  as  suturing  after  circular  resection, 
that  is,  gangrene  of  the  margins  of  the  bowel,  and  perforation. 

Dr.  M.  E.  Connel,  Superintendent  of  the  Milwaukee  County 
Hospital,  suggested  the  use  of  perforated  plates  for  making  the 
lateral  apposition,  in  place  of  suturing.  A  few  crude  experiments 
were  made  with  perforated  discs  of  lead,  wood,  gutta-percha,  and 
leather,  and  the  results  soon  satisfied  us  of  the  expediency  and  greater 
safety  of  uniting  the  intestines  in  this  manner.  Although  the  first 
experiments  were  very  imperfect,  and  faulty  in  technique,  almost 
every  animal  recovered.  In  the  first  experiments  no  needles  were 
used.  Around  the  oval  perforation  four  catgut  or  silk  sutures  were 
tied;  a  slit  was  made  in  the  bowel  on  the  convex  side  parallel  with  its 


DIRECTIONS  FOR   PREPARING   BONE   PLATES.  179 

axis  and  large  enough  to  permit  the  passage  of  a  plate  about  an  inch 
in  width  and  about  two  and  a  half  inches  in  length.  After  making 
the  incision,  and  introducing  the  plate  above  and  below  the  seat  of 
obstruction,  the  two  wounds  were  brought  into  apposition,  and  the 
corresponding  strings  tied  together  with  sufficient  firmness  to  bring 
the  flattened  surfaces  into  accurate  coaptation.  The  threads  were 
cut  short  and  the  ends  pushed  inward  out  of  sight.  Experience 
showed  that  although  the  apposition  was  good,  a  tendency  was 
observed  on  the  part  of  the  margins  of  the  wound  to  evert  on  account 
of  the  bulging  of  the  mucous  membrane.  I  consequently  modified 
the  operation  by  arming  the  lateral  threads  with  a  needle  with  which 
the  margin  of  the  incision  about  the  middle  of  the  wound  was  trans- 
fixed. This  proved  a  step  in  the  right  direction,  as  the  lateral 
sutures  completely  prevented  eversions  of  the  margins  of  the  wound, 
at  the  same  time  they  fixed  the  plates  in  their  position,  and  lastly,  at 
once  transformed  the  longitudinal  slit  into  an  oval  foramen  of  suffi- 
cient size  for  the  free  passage  of  intestinal  contents.  After  many 
trials  with  different  kinds  of  materials  for  the  plates,  I  came  to  the 
conclusion  that  decalcified  or  partially  decalcified  bone  plates,  pre- 
served after  the  decalcification  in  pure  alcohol,  served  the  best 
purpose. 

Directions  for  Preparing-  Bone  Plates. 

The  compact  layer  of  an  ox's  femur  or  tibia  is  cut  with  a  fine 
saw  into  oval  plates,  one-fourth  of  an  inch  in  thickness,  two  and  one- 
half  to  three  inches  in  length,  and  an  inch  in  width.  The  plates  are 
then  decalcified  in  a  ten  per  cent,  solution  of  hydrochloric  acid, 
changed  every  twenty- four  hours  until  they  have  become  sufficiently 
soft  so  that  they  can  be  bent  in  any  direction  without  fracturing. 
After  decalcification  they  are  washed  by  letting  water  flow  over  them 
from  three  to  six  hours  so  as  to  remove  the  acid.  The  plates  are  then 
covered  with  porous  paper  and  compressed  between  two  pieces  of 
tin  imtil  they  are  perfectly  dry.  If  during  the  process  of  drying  the 
plates  are  not  compressed  between  two  smooth  surfaces  they  become 
distorted  by  warping.  The  hardened  plates  are  next  drilled  several 
times  in  a  straight  line  in  the  centre,  and  the  openings  enlarged 
and  connected  with  a  file,  until  the  perforation  is  five-eighths  of 
an  inch  in  length  and  about  one-eighth  to  one-sixth  of  an  inch  in 
width.      The   sharp   margins   of   the   plate   and   perforations   are 


180  INTESTINAL  SURGERY. 

removed  with  a  file.  With  a  fine  drill  the  four  perforations  for  the 
sutures  are  made  near  the  margin  of  the  oblong  perforation,  one  at 
each  end  and  one  at  each  side.  For  preservation  the  plates  are  kept 
in  absolute  alcohol.  When  the  plates  are  to  be  used  they  are 
washed  in  a  two  per  cent,  carbolic  acid  solution,  and  the  threads  or 
sutures  attached  by  threading  two  fine  sewing  needles,  each  with  a 
piece  of  aseptic  silk,  twenty-four  inches  in  length,  which  are  tied 
together.  The  threads  are  then  fastened  to  the  surface  of  the  plate 
by  another  thread  passing  through  the  perforations  in  the  shape  of 
a  loop  and  fastened  at  the  back. 

Instead  of  describing  the  experiments  in  their  chronological 
order,  I  will  enumerate  them  according  to  the  part  of  the  intes- 
tine operated  upon,  commencing  with  the  upper  portion  of  the 
intestinal  tract. 

I.     Gastro-Enterostomy. 

As  gastro-enterostomy  is  an  operation  which  establishes  an 
anastomosis  between  the  stomach  and  the  upper  portion  of  the 
intestinal  canal,  with  exclusion  of  the  duodenum,  and  sometimes  a 
portion  of  the  jejunum,  and  is  performed  in  cases  of  obstruction  in 
the  pylorus  or  duodenum,  it  comes  within  the  legitimate  sphere  of 
this  article.  Gastro-enterostomy,  as  heretofore  described  and  per- 
formed, is  an  operation  attended  by  many  difficulties,  and  requires 
even  in  the  hands  of  an  expert  an  hour  or  more  for  its  execution. 
As  this  operation  is  only  done  in  cases  greatly  debilitated  by  disease 
and  long  suffering,  anything  which  will  simplify  the  technique  and 
shorten  the  time  must  be  looked  upon  as  an  improvement.  An 
operation  that  can  be  done  in  ten  minutes  instead  of  an  hour  or  two, 
and  which  furnishes  even  better  conditions  for  the  healing  of  the 
visceral  wounds,  must  take  the  place  of  the  more  complicated  pro- 
cedures which  so  far  have  only  been  practiced  in  the  hands  of  the 
most  experienced  surgeons. 

Eperiment  54.  Dog,  weight  twenty-five  pounds.  Incision  made  through 
linea  alba  from  xiphoid  cartilage  to  near  umbilicus.  Omentum  pushed  to  one 
side,  and  the  stomach  drawn  forward  into  the  wound;  near  the  middle  of  its 
anterior  surface  a  longitudinal  incision  was  made,  two  inches  in  length,  and  a 
perforated  gutta-percha  plate,  to  which  four  medium-sized  juniper  catgut 
sutures  were  attached,  was  introduced.  The  lateral  sutures,  armed  with 
needles,  were  passed  through  the  entire  thickness  of  the  walls  of  the  stomach, 
half  way  between  the  angles  of  the  wound.     A  similar  incision  was  made  into 


GASTRO-ENTEROSTOMY.  181 

the  intestine  at  the  junction  of  the  duodenum  with  the  jejunum;  the  same 
kind  of  plate  introduced,  and  the  margins  of  the  wound  punctured  by  the 
lateral  armed  sutures,  when  the  two  wounds  were  brought  vis-a-vis  and  the 
corresponding  sutures  tied.  In  tying  the  sutures,  the  lower  lateral  suture  was 
tied  first  and  the  threads  cut  short;  next  the  sutures  corresponding  to  each 
angle  of  the  wound  were  tied,  and  lastly  the  upper  lateral.  The  serous  surfaces 
of  the  stomach  and  intestine  over  an  area  corresponding  to  the  size  of  the 
plates  were  brought  into  accurate  permanent  contact  by  the  tying  of 
the  sutures.  The  stomach  was  replaced  and  the  abdominal  wound  closed. 
The  animal  was  allowed  to  eat  immediately  after  the  operation,  manifested 
no  signs  of  illness  or  pain,  and  was  killed  seven  days  after  operation. 
Abdominal  wound  healed.  Omentum  adherent  to  its  inner  surface.  Union 
between  stomach  and  bowel  firm  over  the  entire  surface  of  approximation. 
Plates  detached,  the  one  in  the  bowel  had  passed,  while  the  other  was  found 
loose  in  the  stomach.  The  new  opening  large  enough  to  admit  the  index 
finger. 

Experiment  55.  Dog,  weight  fifty  pounds.  The  operation  was  performed 
in  the  same  manner  as  in  the  previous  experiment,  but  great  diflSculty  was 
experienced  in  bringing  the  stomach  forward,  as  this  organ  was  distended  to 
its  utmost  with  an  enormous  quantity  of  solid  food.  Evacuation  was  effected 
through  the  incision,  aided  by  attempts  of  the  animal  to  vomit,  the  violent 
contractions  of  the  stomach  forcing  the  food  toward  the  opening,  from  which 
it  was  removed  with  fingers  and  spoon.  After  the  stomach  was  emptied  it  was 
washed  out  with  warm  water.  For  the  stomach  a  bone  plate,  only  partially 
decalcified,  was  used,  while  the  approximation  plate  in  the  bowel  was  fully 
decalcified.  The  four  approximation  sutures  were  of  catgut.  Several  portions 
of  omentum,  which  were  soiled  during  the  emptying  of  the  stomach,  were 
excised.  The  abdominal  cavity  was  thoroughly  irrigated  with  warm  water 
before  the  wound  was  closed.  The  animal  died  the  next  day,  and  on  opening 
the  abdomen  it  was  ascertained  that  the  immediate  cause  of  death  was 
htemorrhage,  as  the  peritoneal  cavity  was  filled  with  blood.  The  bleeding 
undoubtedly  took  place  from  the  omentum,  by  slipping  or  loosening  of  one 
of  the  catgut  ligatures. 

Experiment  56.  Medium-sized  dog.  Operation  performed  in  the  same 
manner  with  decalcified  bone  plates  and  catgut  sutures.  The  first  two  days 
the  animal  had  several  attacks  of  vomiting,  subsequently  showed  no  signs  of 
suffering.  Appetite  good  and  stools  regular.  Killed  thirty-four  days  after 
operation.  Omentum  adherent  to  inner  surface  of  abdominal  wound.  At 
point  of  operation  stomach  was  contracted,  so  that  the  organ  presented  an 
hour-glass  appearance.  Interior  of  the  organ  contained  a  large  mass  of  hay 
and  fragments  of  bone.  New  opening  large  enough  to  pass  index  finger. 
Union  between  stomach  and  bowel  over  entire  surface  of  approximation. 
Water  passed  into  the  stomach  flowed  through  the  pyloric  orifice  and  the  new 
opening,  in  a  stream  of  equal  size. 

Experiment  57.  Large  bull-dog.  Approximation  of  anterior  surface  of 
stomach  with  bowel  by  perforated  gutta-percha  plates,  and  four  catgut  sutures. 


182  INTESTINAL  SURGERY. 

Length  of  visceral  incisions,  two  inches.  The  day  after  operation  animal 
vomited  his  dinner,  subsequently  no  unfavorable  symptoms.  Animal  killed 
fourteen  days  after  operation.  Abdominal  wound  well  united.  Omentum 
adherent  to  wound,  duodenum,  liver  and  at  point  of  operation.  Firm  adhe- 
sions between  stomach  and  bowel.  Water  passed  into  the  stomach  only 
passed  through  the  pyloric  orifice.  On  opening  the  stomach,  it  was  found 
that  the  wound  in  the  stomach  and  intestine  had  completely  healed,  the  site  of 
incisions  being  marked  by  a  narrow  firm  cicatrix.  The  failure  of  obtaining 
an  anastomotic  opening  between  the  stomach  and  intestine  could  only  be 
attributed  to  one  of  two  causes,  viz.:  either  the  perforations  in  the  plates  were 
too  narrow,  or  the  needles  of  the  lateral  sutures  included  too  much  tissue. 
Either  cause  would  bring  about  approximation  of  the  margin  of  the  wounds 
and  permanent  closure  of  the  opening  by  granulation  and  cicatrization. 

Remarks. — All  of  the  animals  recovered,  except  in  case  of 
experiment  55,  without  any  untoward  symptoms,  although  they 
were  allowed  to  eat  immediately  after  the  operation,  and  the  diet 
was  not  selected  or  restricted  at  any  time.  In  the  fatal  case  death 
was  caused  from  complications  which  had  no  connection  with  the 
gastro- intestinal  opening.  In  all  of  the  specimens  examined,  the 
mucous  membrane  of  the  stomach  and  intestine  which  had  been 
interposed  between  the  approximation  plates,  presented  a  healthy 
appearance,  showing  that  the  pressure  of  the  plates  had  exercised 
no  injurious  effect  on  this  structure.  More  recent  experience  with 
this  operation  on  animals  has  revealed  the  fact  that  in  the  stomach 
a  completely  decalcified  bone  plate  is  almost  entirely  digested  in 
thirty-six  to  forty-eight  hours.  It  would  therefore,  appear  advisable 
to  use  only  partially  decalcified  bone  which  remains  for  a  longer 
time,  so  that  in  case  of  delayed  union  the  approximation  would 
be  maintained  for  a  sufificient  length  of  time.  As  the  animals 
subjected  to  the  operation  recovered  promptly,  and  under  the  most 
unfavorable  conditions,  we  have  every  reason  to  believe  that  this 
operation  will  be  attended  by  the  same  favorable  results  when  done 
for  pyloric  or  duodenal  stenosis  in  man,  where  a  careful  preparatory 
and  after  treatment  cannot  fail  to  facilitate  the  operation  and  to 
improve  the  conditions  for  the  formation  of  early  adhesions  and  a 
speedy  definitive  healing  of  the  wound.  I  have  no  hesitation  in 
recommending  it  as  a  substitute  for  the  more  time-consuming  and 
les3  certain  operation  by  the  tedious  and  difificult  method  of  double 
suturing  which  is  now  generally  practiced. 


JEJUNO-ILEOSTOMY.  183 

2.     Jejuno-Ileostomy. 

In  this  operation  some  form  of  intestinal  obstiTiction  was  made ; 
either  complete,  by  division  of  the  bowel  and  closure  of  both  ends, 
or  partial,  by  making  a  volvulus,  invagination  or  flexion  in  the  vicinity 
of  the  juncture  of  the  jejunum  with  the  ileum,  followed  by  estab- 
lishing a  communication  between  the  bowel  above  and  below  the 
obstruction.  Before  I  made  use  of  the  perforated  approximation 
discs,  this  was  accomplished  by  making-  an  incision  an  inch  and  a  half 
or  two  inches  in  length  through  the  convex  surface  of  the  bowel 
above  and  below  the  obstruction,  and  uniting  the  wounds  by  a  double 
row  of  sutures.  An  operation  of  this  kind  usually  lasted  over  an 
hour,  while  the  rapid  operation  of  coaptation  by  perforated  discs 
seldom  took  more  than  fifteen  minutes. 

a.     Jejuno-Ileostomy  by  Suturing. 

Experiment  58.  Large  cat.  Invagination  of  ileum  into  ileum  in  a  down- 
ward direction,  and  fixation  of  intussusceptum  to  neck  of  intussuscipiens  by 
two  fine  catgut  sutures  to  prevent  spontaneous  reduction.  Intestinal  anasto- 
mosis by  establishing  an  opening  an  inch  in  length,  suturing  by  Czerny- 
Lembert  method.  The  animal  never  recovered  from  the  shock  of  the 
operation,  and  died  in  less  than  twenty-four  hours.  Length  of  intussusceptum 
two  inches,  which,  after  the  removal  of  the  sutures,  could  not  be  reached  by 
traction,  as  the  bowel  was  firmly  constricted  by  the  neck  of  the  intussuscipiens, 
and  recent  adhesions  had  formed.     No  peritonitis;  suturing  found  perfect. 

Experiment  59.  Dog,  weight  sixty-five  pounds.  Intestinal  obstruction  by 
making  acute  flexions  in  upper  portion  of  ileum;  fixation  of  loops  of  intestine 
by  fine  catgut  sutures.  Intestinal  anastomosis  between  jejunum  and  ileum 
by  incision  and  double  suturing.  The  animal  died  on  third  day  with  symp- 
toms of  perforative  peritonitis.  On  close  examination,  one  of  the  superficial 
approximation  sutures  had  been  passed  through  the  whole  thickness  of  the 
wall  of  the  bowel,  and  it  was  here  that  perforation  had  taken  place.  Recent 
diffuse  general  peritonitis. 

Experiment  60.  Dog,  weight  seventeen  pounds.  Descending  invagination 
of  ileum  into  ileum,  length  of  intussusceptum  three  inches,  fixation  by  two 
catgut  sutures.  Formation  of  intestinal  anastomosis  between  the  bowel 
above  and  below  the  invagination  by  incision  and  double  suturing.  Animal 
died  on  third  day  with  symptoms  of  perforative  peritonitis.  Abdominal 
wound  not  united.  Adhesions  at  point  of  operation  quite  firm.  Diffuse 
general  peritonitis  from  a  perforation  which  had  been  made  by  a  sharp 
fragment  of  bone  above  the  new  opening.     Intussusceptum  not  gangrenous. 

Experiment  61.  Dog,  weight  twenty-three  pounds.  Intestinal  obstruction 
was  made  by  producing  a  volvulus  in  the  upper  part  of  the  ileum.  Restora- 
tion of  continuity  of  intestinal  canal  by  making  a  jejuno-ileostomy  by  lateral 


184  INTESTINAL   SURGERY. 

apposition  and  double  suturing.  Day  after  operation  intestinal  discharges 
were  bloody;  after  this  time  normal.  Animal  in  perfect  health  when  killed 
sixty-seven  days  after  operation.  The  volvulus  was  found  in  same  condition 
as  after  operation;  the  intestinal  loop  empty,  atrophied  and  adherent  to 
adjacent  loops  of  intestine.  Bowel  above  seat  of  obstruction  and  as  far  as 
the  new  opening  empty.  Intestinal  tract  above  and  below  the  obstruction 
presented  no  indication  of  the  presence  of  an  obstruction.  New  opening  oval 
in  shape  and  as  large  as  the  lumen  of  the  bowel  at  that  point. 

Experiment  62.  Large  Maltese  cat.  Intestinal  obstruction  by  making 
two  flexions  in  ileum,  about  eighteen  inches  apart,  after  this  portion  had  been 
cleared  of  its  contents.  Flexions  made  by  doubling  the  bowel  toward  its 
convex  side,  and  fixing  it  in  this  position  by  fine  catgut  sutures.  Jejuno- 
ileostomy  by  lateral  apposition  and  suturing.  Vomiting  day  after  operation; 
stools  scanty  the  first  few  days,  and  later  complete  obstruction.  Died  nineteen 
days  after  operation.  Wound  completely  united;  no  general  peritonitis; 
flexions  remained;  bowel  between  them  contained  a  slight  amount  of  faecal 
matter.  Bowel  some  distance  above  the  new  opening  very  much  dilated, 
pointing  to  obstruction  above  new  opening.  On  tracing  the  intestinal  canal 
from  above  downward,  this  obstruction  was  seen  to  consist  in  acute  flexion  of 
the  bowel  by  firm  and  extensive  adhesions.  New  opening  sufficiently  large  to 
admit  the  tip  of  the  index  finger,  around  the  margins  of  which  most  of  the 
deep  sutures  remained  attached. 

Experiment  63.  Large  cat.  Obstruction  made  by  two  flexions  in  the 
ileum,  the  apices  of  which  were  united  by  catgut  sutures.  Intestinal  anasto- 
mosis made  by  a  jejuno-ileostomyi  For  eleven  days  the  animal  remained  in 
good  condition,  when  symptoms  of  perforative  peritonitis  manifested  them- 
selves, and  death  ensued  two  days  later.  External  portion  of  wound  not 
united.  Numerous  omental  and  intestinal  adhesions.  Flexions  retained  and 
their  apices  adherent  to  each  other  by  firm  band  of  adhesion.  Excluded 
portions  above  and  below  the  obstruction  empty.  Two  small  perforations  at 
point  of  suturing  on  anterior  surface  of  bowel;  remaining  portion  of  wound 
firmly  united.  New  opening  sufficiently  large  to  admit  tip  of  index  finger. 
Death  from  perforative  peritonitis. 

Experim,ent  64.  Large,  Newfoundland  dog.  Descending  invagination  of 
ileum  into  ileum  to  the  extent  of  six  inches;  fixation  of  intussusceptum  by  two 
catgut  sutures.  Permeability  of  intestinal  canal  restored  by  making  a  jejuno- 
ileostomy;  wounds  united  by  a  double  row  of  sutures.  Intestinal  discharges 
normal  throughout.  No  rise  in  temperature.  General  condition  as  good  as 
before  operation,  when  killed  on  the  twentieth  day.  Abdominal  wound  com- 
pletely united;  no  peritonitis;  omentum  adherent  at  site  of  operation. 
Invagination  had  reduced  itself,  and  its  location  was  marked  by  an  acute 
flexion  caused  by  extensive  adhesions.  No  accumulation  of  intestinal  contents 
in  excluded  portions.  The  new  opening  at  least  two  inches  in  length;  a  few 
of  the  deep  sutures  remained  attached  to  its  margins.  This  opening  was 
partially  obstructed  by  a  mass  of  hair  and  fragments  of  bone. .  On  passing  a 
stream  of  water  from  above  downward,  the  fluid  passed  through  an  opening  in 


JEJUNO-ILEOSTOMY.  185 

the  centre  of  this  mass  into  the  lower  portion  of  the  ileum,  but  not  through  the 
portion  that  was  invaginated.  After  this  mass  was  removed,  the  iiuid  was 
found  to  pass  through  the  portion  that  was  invaginated,  as  well  as  through  the 
new  opening. 

The  many  failures  which  attended  jejiino-ileostomy  and  ileo- 
ileostomy  by  lateral  apposition  and  suturing,  led  to  the  use  of 
perforated  approximation  discs.  A  great  contrast  was  observed  in 
the  animals  operated  upon  by  these  two  methods.  The  operation  by 
suturing  required  usually  more  than  an  hour,  and  almost  all  of  the 
animals  showed  more  or  less  symptoms  of  shock  after  its  completion, 
and  not  a  few  succumbed  to  its  immediate  effects ;  while  the  opera- 
tion by  approximation  plates  could  always  be  finished  within  twenty 
minutes,  consequently  the  animals  never  suffered  seriously  from  the 
immediate  effects  of  the  operation.  The  first  experiments  were 
made  somewhat  carelessly  and  with  crude  material,  and  yet  it  was 
observed  that  the  healing  process  progressed  more  favorably  and 
was  accomplished  in  a  shorter  time  than  after  suturing.  The 
approximation  discs  brought  into  uninterrupted  contact  large  serous 
surfaces  without  impairing  the  vascular  supply;  at  the  same  time 
they  secured  for  the  parts  destined  to  become  united  an  essential 
condition   for   rapid   wound  healing — rest — by  serving   the  useful 

purpose  of  splints. 

Experiment  63.  Dog,  weight  fifteen  pounds.  Ileum  was  completely 
divided  at  its  junction  with  the  jejunum  and  both  ends  of  the  bowel  closed  by 
invagination,  and  three  stitches  of  the  continued  suture.  An  incision  was 
made  on  convex  side  of  bowel  about  two  inches  from  the  closed  ends,  and  a 
heavy  perforated  lead  plate  to  which  six  catgut  sutures  were  fastened  around 
the  oval  perforation,  was  introduced  into  the  lumen  of  the  bowel  of  each  closed 
end,  all  of  the  catgut  sutures  being  brought  out  through  the  incision.  The 
two  wounds  were  brought  opposite  each  other  and  the  six  sutures  tied.  The 
serous  surfaces  of  the  two  intestines  over  a  surface  corresponding  to  the  size 
of  the  lead  discs  were  thus  brought  into  accurate  apposition.  The  sutures 
were  cut  short  and  the  ends  buried  as  deeply  as  possible.  The  condition  of 
the  animal  remained  excellent  until  the  time  of  killing,  seventy-five  days  after 
operation.  Omentum  adherent  to  wound;  large  intestines  distended  with 
normal  faeces.  Bowel  above  and  below  point  of  operation  normal  in  size  and 
structure.  New  opening  between  ileum  and  jejunum  large  enough  to  admit 
the  little  finger  to  second  joint.  Bowels  firmly  united  by  a  broad  surface. 
Above  the  communicating  opening  a  double  flexion  of  the  bowel  was  found 
which  apparently  had  done  no  harm. 

Experiment  66.  Dog,  weight  eighteen  pounds.  Operation  done  in  the 
same  manner  as  in  the  last  experiment,  only  that  instead  of  lead  the  discs 
were  made  of  sole  leather,  and  the  sutures  used  were  linen  in  place  of  catgut. 


186  INTESTINAL  SURGERY. 

For  a  few  days  the  temperature  was  higher  than  normal  and  appetite  dimin- 
ished. After  fourth  day  the  animal  appeared  to  be  in  excellent  condition  and 
remained  so  for  three  weeks,  when  the  appetite  failed  and  occasional  attacks 
of  vomiting  set  in.  The  symptoms  remained  more  or  less  prominent  until 
the  time  of  killing,  thirty-nine  days  after  operation.  Omentum  adherent  to 
abdominal  wound  ;  extensive  intestinal  adhesions  at  site  of  operation  ;  union 
between  intestines  perfect.  On  incising  the  bowel  it  was  found  that  the  plates 
had  sloughed  through,  and  had  passed  along  the  distal  portion  of  the  bowel, 
leaving  an  opening  the  size  of  the  plates,  the  margins  of  which  had  almost 
completely  cicatrized.  The  two  leather  plates,  still  held  together  by  the  linen 
sutures,  were  found  three  feet  lower  down  in  the  ileum,  where  they  had  become 
embedded  in  a  mass  of  hair,  straw  and  faecal  matter,  and  quite  firmly  impacted, 
causing  complete  obstruction  of  the  bowel.  The  intestine  above  the  seat  of 
obstruction  was  enormously  dilated,  while  below  the  seat  of  impaction  it  was 
empty  and  contracted.  Large  intestines  likewise  empty  and  contracted.  The 
cause  of  the  illness  was  evidently  due  to  intestinal  obstruction  produced  by 
the  impaction  of  the  large  enterolith,  in  the  center  of  which  the  leather  discs 
were  found. 

Experiment  67.  Dog,  weight  ten  pounds.  In  this  instance  the  bowel  was 
divided  near  the  junction  of  the  jejunum  with  the  ileum,  both  ends  closed, 
and  its  continuity  established  by  incising  the  convex  surface  of  both  ends, 
and  approximating  the  wounds  by  two  perforated  bone  plates  tied  together 
by  silk  ligatures.  The  animal  died  fourteen  days  after  operation.  During 
the  last  few  days  symptoms  of  intestinal  obstruction  were  present.  Abdominal 
wound  completely  united.  Numerous  intestinal  adhesions  at  site  of  operation. 
Bone  plates  stiU  in  situ  and  firmly  fixed.  On  proximal  side,  perforation  of 
bone  plates  completely  closed  by  hair  and  fragments  of  bone,  giving  rise  to 
complete  intestinal  obstruction.  The  bowel  above  tWs  point  was  greatly 
dilated,  while  on  distal  side  it  was  empty  and  contracted.  Firm  adhesions 
between  the  two  intestinal  surfaces  included  by  the  bone  plates.  Intestinal 
obstruction  by  a  mechanical  arrest  of  j)ortion  of  the  intestinal  contents  above 
the  proximal  plate  had  caused  death  before  a  more  efficient  communication 
could  be  established  by  sloughing  through  of  the  bone  plates. 

Experiment  68.  Dog,  weight  thirty  pounds.  Ileo-ileostomy  by  dividing 
the  ileum  near  its  centre,  closing  both  sides,  and  after  incising  both  eiids 
on  convex  surface,  bringing  wounds  in  apposition  by  perforated  plates  of 
cross-grained  walnut  wood,  which  were  tied  together  with  silk  sutures.  The 
dog  remained  in  perfect  health  and  was  killed  eighteen  days  after  operation. 
External  wound  completely  united.  Plates  had  become  detached,  leaving  a 
communicating  opening  two  inches  in  length.  Blind  ends  of  bowel  empty; 
no  trace  of  plates  could  be  fouiid. 

Experiment  69.  Dog,  weight  twenty -four  pounds.  Double  ileo-ileostomy. 
Ileum  divided  transversely  five  inches  above  ileo-caecal  region,  and  both  ends 
closed  by  invagination  and  three  stitches  of  the  continued  suture.  Lower 
and  upper  end  of  bowel  were  again  brought  into  communication  by  incision 
on  convex  side,  and  lateral  apposition  of   wounds  by  means  of  perforated 


JEJUNO-ILEOSTOMY.  1S7 

approximation  plates  of  decalcified  bone,  hardened  in  alcohol.  The  plates 
were  fastened  together  by  four  silk  sutures,  all  of  the  threads  being  brought 
out  of  the  incision,  tied  and  cut  short.  Above  this  point  a  loop  of  the  ileum 
was  made  by  bringing  the  convex  surfaces  into  apposition  after  incision  at 
two  points,  and  introducing  perforated  gutta-percha  plates,  which  were 
retained  in  place  by  four  silk  sutures.  No  fever  or  symptoms  of  obstruction 
followed  the  operation.  Animal  killed  thirteen  days  later.  External  wound 
firmly  united.  No  evidences  of  peritonitis  or  intestinal  obstruction.  First 
operation  left  a  communicating  opening  large  enough  to  admit  the  little 
finger  in  one  of  its  margins.  The  silk  ligatures  which  had  become  detached 
from  the  plates  had  embedded  themselves.  The  decalcified  bone  plates  had 
disappeared  and  no  trace  of  them  could  be  found  in  any  portion  of  the  intes- 
tinal canal  lower  down.  The  second  operation  was  thirty  inches  higher  up. 
Gutta-percha  plates  remained  in  situ,  although  somewhat  loosened  by  the 
gradual  disappearance  of  the  intervening  tissues  by  pressure  atrophy. 
Adhesions  between  the  two  surfaces  of  the  bowel  firm,  and  extending  a  little 
beyond  the  line  of  approximation.  The  perforation  in  the  proximal  plate 
almost  completely  closed  by  an  accumulation  of  hair.  The  entire  ileum 
normal  in  size  and  appearance. 

Experiment  70.  Dog,  weight  fifty-four  pounds.  Transverse  section  of 
ileum  thirty  inches  above  ileo-csecal  region  and  closure  of  both  ends  in  the 
usual  manner.  The  two  closed  ends  were  overlapped  four  inches  and  brought 
into  communication  by  two  longitudinal  openings,  which  were  approximated 
by  being  buttoned  together  with  a  shuttle-shaped  button,  nearly  one  and  a 
half  inches  in  length,  the  sides  being  lead  plates  and  the  shaft  a  rubber  tube 
through  which  the  anastomosis  was  established  at  once.  As  the  margins  of 
the  intestinal  wounds  showed  a  tendency  to  evert,  a  fine  catgut  suture  was 
inserted  on  each  side  embracing  only  the  peritoneal  coat.  Only  for  two  or 
three  days  after  the  operation  did  the  dog  not  appear  to  be  well.  Killed 
twenty-three  days  after  operation.  Omentum  adherent  to  abdominal  wound 
which  was  firmly  united.  Omental  adhesions  to  intestine  at  site  of  operation. 
Intestinal  anastomosis  thirty  inches  above  the  ileo-csecal  valve.  Proximal 
blind  end  of  bowel  five  inches  in  length  adherent  to  distal  end,  considerably 
dilated  and  contained  fragments  of  bone  and  other  crude  substances.  Approx- 
imation button  in  situ  and  quite  firmly  fixed.  A  fragment  of  bone  partly  filled 
the  lumen  of  the  rubber  tube.  Coaptated  peritoneal  surfaces  firmly  adherent. 
The  obstruction  of  the  communicating  tube  had  given  rise  to  dilatation  of  the 
bowel  above  the  point  to  twice  its  natural  size,  while  below  the  seat  of  partial 
obstruction  the  intestine  appeared  empty  and  contracted. 

Experiment  71.  Small  dog.  In  this  experiment  the  ileo-ileostomy  was 
made  by  lateral  apposition  by  perforated  approximation  plates  of  partially 
decalcified  bone  tied  together  by  four  catgut  sutures.  The  lateral  sutures  were 
passed  through  the  margins  of  the  wound  near  its  border,  a  modification  of 
the  usual  procedure,  which  not  only  fixed  the  plates  firmly  in  their  places,  but 
also  prevented  ectropium  of  the  mucous  membrane,  and  ensured  free  patency 
of  the  new  opening  by  retracting  the  margins  of  the  wound,  so  that  the  longi- 


188  INTESTINAL  SURGERY. 

tudinal  slit  was  at  once  transformed  into  an  oval  shape.  The  animal  showed 
no  unfavorable  symptoms  and  was  killed  twenty-nine  days  after  operation. 
Dog  well  nourished.  External  wound  united.  Omentum  adherent  to  wound 
and  intestines.  The  proximal  blind  end  of  bowel  contained  one  of  the  bone 
plates  which  showed  signs  of  softening  and  disintegration.  The  bone  plate 
in  the  distal  end  had  been  passed  with  faeces  previously.  The  new  opening 
perfect  and  sufficiently  large  to  equal  in  size  the  lumen  of  the  bowel. 

Experiment  72.  Dog,  weight  twelve  pounds.  Made  ileo-ileostomy  the 
same  as  in  the  last  experiment,  using  decalcified  perforated  bone  plates, 
which  were  tied  together  with  four  catgut  sutures,  the  lateral  ones  being 
passed  through  the  margins  of  the  wound.  An  omental  flap  was  used  to  cover 
the  sides  of  the  bowel  where  approximation  had  been  made.  This  flap  was 
retained  by  two  fine  catgut  sutures.  No  unfavorable  symptoms.  Animal 
killed  twenty-three  days  after  operation.  Omentum  adherent  to  distal  blind 
end.  Omental  flap  in  position  and  firmly  adherent.  Site  of  operation  four- 
teen inches  above  ileo-caecal  region.  Both  bone  plates  had  disappeared  and 
no  trace  of  them  could  be  found.  Some  hair  had  collected  in  the  blind  proxi- 
mal end.     New  opening  large  enough  to  admit  the  index  finger. 

Remarks. —  Jejuno- ileostomy  or  ileo-ileostomy  by  internal 
apposition  with  decalcified  perforated  bone  plates  in  cases  of  com- 
plete obstruction  of  the  bowel  artificially  produced,  is  an  operation 
almost  devoid  of  danger.  Partially  or  completely  decalcified  bone 
plates  hardened  in  alcohol  remain  firm  for  a  sufficient  length  of  time 
to  answer  the  purpose  of  retentive  measures,  until  firm  adhesions 
have  formed  between  the  serous  surfaces  held  by  them  in  approxi- 
mation. Until  it  was  ascertained  by  experiment  that  the  plates 
would  undergo  softening  and  disintegration  in  the  course  of  a  few 
days,  catgut  sutures  were  used  to  hold  them  in  place  with  the 
expectation  that  the  plates  would  become  detached  and  escape  with 
the  intestinal  contents  as  soon  as  the  sutures  would  give  way. 
Experience,  however,  has  shown  that  aseptic  silk  threads  are  prefer- 
able to  catgut,  as  they  can  be  tied  with  greater  accuracy  and  the 
knots  will  never  become  loosened,  while  the  approximation  discs 
disppear  completely  by  softening  and  disintegration  in  a  few  days. 
Approximation  plates  of  inabsorbable  material  as  lead,  wood,  leather, 
bone,  and  gutta-percha,  fastened  together  by  silk  or  linen  sutures, 
remain  in  situ  until  the  interposed  tissues  disappear  by  pressure 
atrophy,  and  the  opening  that  results  corresponds  in  size  to  the 
dimensions  of  the  plates.  In  the  first  experiments  the  plates  were 
tied  together  by  six  sutures,  but  it  was  found  that  four  svitures 
answered  the  same  purpose.     As  a  rule  the  plates  were  about  two 


ILEO-COLOSTOMY.  189 

and  a  half  inches  in  length,  and  their  width  corresponded  to  one- 
third  of  the  circtimference  of  the  bowel.  The  greatest  advantage  to 
be  found  in  the  method  of  restoring  the  continuity  of  the  intestinal 
canal  by  lateral  apposition  by  approximation  discs,  consists  in  the 
fact  that  the  point  of  contact  is  always  made  on  the  convex  surface 
of  the  intestines,  so  that  the  means  employed  to  secure  coaptation 
do  not  interfere  with  the  blood  supply  from  the  mesenteric  vessels. 
As  this  method  requires  much  less  time  than  any  form  of  circular 
enterorrhaphy,  and  has  been  followed  almost  without  exception  by 
recovery,  it  recommends  itself  strongly  as  a  substitute  for  the  latter 
procedure  in  many  cases  where  loss  of  time  constitutes  an  important 
factor  in  the  issue  of  the  case,  or  where  from  other  causes  circular 
suturing  appears  impossible  or  impracticable. 

3.     Ileo-Colostomy. 

As  the  ileo-cfecal  region  is  frequently  the  seat  of  intestinal 
obstruction,  it  becomes  desirable  to  devise  some  definite  plan  of 
operative  treatment  in  cases  where  the  cause  of  obstruction  is  not 
amenable  to  removal,  with  a  view  of  establishing  the  continuity  of 
the  intestinal  canal,  thus  avoiding  the  necessity  of  resorting  to  the 
formation  of  an  artificial  anus.  To  accomplish  this  object  two 
distinct  methods  were  followed  :  1.  Division  of  the  ileum  with 
closure  of  distal  and  implantation  of  proximal  end  into  colon.  2. 
Division  of  ileum,  closure  of  both  ends  and  lateral  apposition  of 
proximal  end  with  colon,  and  the  formation  of  an  intestinal  anasto- 
mosis by  suturing  or  approximation  discs. 

a.    Ileo-Oolostomy  by  Implantation. 

Experiment  73.  Dog,  weight  thirty-eight  pounds.  Intestinal  anastomosis 
by  implantation  of  ileum  into  colon.  The  ileum  was  divided  transversely 
just  above  the  ileo-csecal  region,  and  the  distal  end  closed  by  invagination  and 
three  stitches  of  the  continued  suture,  and  dropped  back  into  the  abdominal 
cavity.  A  longitudinal  incision,  in  size  corresponding  to  the  lumen  of  the 
ileum,  was  made  in  the  ascending  colon  at  a  point  directly  opposite  the 
mesentric  attachment,  and  the  proximal  end  of  the  ileum  was  then  fixed  in 
this  opening  by  Czerny-Lembert  sutures.  Only  slight  febrile  reaction  followed 
the  operation.  The  appetite  remained  good  and  the  discharges  from  the 
bowels  were  normal.  The  animal  was  in  excellent  condition  when  killed, 
thirty-three  days  after  operation.  Few  circumscribed  omental  adhesions  to 
abdominal  wound,  which  was  completely  closed.  Peripheral  portion  of  ileum 
presented  a  conical  appearance,  and  was  found  adherent  to,  and  of  the  same 
length  as  the  appendix  vermiformis.     Implantation  had  been  done  about  the 


190  INTESTINAL  SURGERY. 

middle  of  the  colon.  Union  at  point  of  suturing  perfect,  apparently  no 
interruption  of  continuity  of  peritoneal  surface.  The  new  opening  into 
colon  a  little  smaller  than  the  lumen  of  the  ileum.  Around  the  margins  of 
this  opening,  which  somewhat  resembled  the  ileo-cgecal  valve,  six  of  the  deep 
silk  sutures  remained  attached.  Above  the  new  opening  the  colon  and  caecum 
were  found  empty  and  somewhat  atrophic.  Lower  portion  of  the  ileum  and 
colon  below  the  new  opening  appeared  normal  in  size  and  structure. 

Remarks. — In  the  remaining  experiments  the  implantation  was 
made  by  lining  the  proximal  end  of  the  ileum  with  a  narrow  flexible 
rubber  ring,  which  was  retained  in  place  by  a  continued  catgut 
suture,  embracing  the  free  margin  of  the  bowel  and  the  lower  margin 
of  the  rubber  ring.  The  implantation  was  made  by  two  catgut 
sutures,  threaded  each  by  two  needles  and  passed  at  opposite  points 
from  within  outwards  through  the  upper  margin  of  the  ring  and  the 
entire  thickness  of  the  bowel,  while  the  needles  were  only  passed 
through  the  serous  and  muscular  coats  of  the  colon.  After  both 
sutures  were  in  place  gentle  traction  upon  all  of  the  ends  brought 
the  end  of  the  ileum  into  the  incision  in  the  colon,  and  the  walls  of 
the  colon  were  drawn  over  the  end  of  the  ileum  to  the  points  where  the 
needles  emerged  from  the  ileum,  making  really  a  limited  invagination. 
When  in  proper  position,  the  serous  surfaces  of  the  colon  and  ileum 
over  a  surface  corresponding  to  the  width  of  the  rubber  ring  were  in 
accurate  coaptation,  after  the  two  sutures  were  tied.  Only  in  excep- 
tional cases  was  it  found  necessary  to  apply  one  or  two  additional 
superficial  coaptation  sutures.  As  in  circular  enterorrhaphy,  so  in 
these  cases,  the  elastic  pressure  on  the  part  of  the  rubber  ring  ren- 
dered material  assistance  in  maintaining  accurate  coaptation,  while 
at  the  same  time  it  secured  rest  for  the  sutured  parts,  and  kept  the 
new  opening  freely  patent  for  the  escape  of  intestinal  contents  into 
the  colon.  This  operation  did  not  require  one-fourth  of  the  time 
consumed  in  making  an  implantation  by  Czerny-Lembert  sutures. 

Experiment  7i.  Dog,  weight  ^ fifty  pounds.  Division  of  ileum  eight 
inches  above  ileo-csecal  region,  distal  end  closed  by  invagination,  and  three 
stitches  of  the  continued  suture.  Proximal  end  lined  with  rubber  ring  and 
implanted  into  incision  of  ascending  colon  by  two  catgut  invagination  sutures. 
The  dog  did  not  appear  to  do  well  after  the  operation,  and  died  on  the  fifth 
day.  Abdominal  wound  not  united.  Partial  separation  of  implanted  bowel 
and  dififuse  septic  peritonitis  from  perforation. 

Experiment  75.  Dog,  weight  thirty-five  pounds.  Ileum  divided  twelve 
inches  above  ileo-csecal  region,  distal  end  closed  and  proximal  end  lined  with 
flexible  rubber  ring  and  implanted  into  an  incision  in  the  transverse  colon, 


ILEO-COLOSTOMY.  191 

and  retained  by  two  invagination  sutures  of  catgut.  An  omental  flap  an  inch 
and  a  half  in  width  was  placed  over  the  junction  of  the  two  intestines  and  fixed 
in  its  place  by  two  catgut  sutures.  No  unfavorable  symptoms  after  operation. 
Animal  when  killed  eighteen  days  later,  in  excellent  condition.  Omentum 
adherent  to  abdominal  wound  which  was  firmly  united.  Omental  flap  adherent 
all  round.  Colon  above  new  opening  ten  inches  in  length,  completely  empty, 
contracted  and  atrophic.  New  opening  oval  in  outline  and  as  large  as  the 
lumen  of  the  ileum. 

Experiment  76.  Dog,  weight  sixteen  pounds.  Division  of  ileum,  closure 
of  distal  end  and  implantation  of  proximal  into  an  incision  of  the  colon  by 
rubber  ring  and  two  invagination  sutures  of  catgut.  As  the  inverted  portions 
of  the  colon  showed  a  tendency  to  evert,  two  additional  retaining  sutures  of 
fine  catgut  were  used,  which  secured  perfect  coaptation  throughout.  An 
omental  flap  was  laid  over  the  junction  of  the  intestines  and  fixed  in  its 
place  by  one  catgut  suture.  The  dog  remained  in  good  condition,  appetite 
unimpaired,  and  discharges  from  bowels  normal.  Killed  thirteen  days  after 
operation.  Abdominal  wound  firmly  united.  Omentum  adherent  to  wound. 
A  number  of  adhesions  between  coils  of  intestine.  Ileum  somewhat  dilated 
above  the  new  opening.  Omental  flap  in  place  and  adherent.  Union  between 
ileum  and  colon  perfect.  A  long,  sharp  fragment  of  bone  was  found  lodged 
just  above  the  new  opening,  the  lower  end  partially  occluding  its  lumen.  The 
dilatation  of  the  lower  portion  of  the  ileum  was  evidently  due  to  partial 
obstruction  from  the  presence  of  the  foreign  body  in  the  new  opening. 

Exjjeriment  77.  Dog,  medium  size.  Section  of  ileum  two  feet  above  the 
ileo-caecal  region,  closure  of  distal  end  in  the  usual  manner,  implantation  of 
proximal  end  into  colon  by  rubber  ring  and  two  invagination  sutures  of  cat- 
gut. No  omental  flap.  Animal  remained  weU  and  was  killed  forty-three 
days  after  operation.  Omentum  adherent  to  abdominal  wound.  Distal  end 
of  ileum  conical  in  shape,  the  extremity  presenting  a  cup-shaped  depression, 
which  was  filled  with  cicatricial  material.  Omentum  adherent  at  ileo-C£ecal 
region  and  at  site  of  operation.  Union  between  the  bowels  perfect  and  their 
serous  surfaces  appeared  to  be  continuous  over  the  line  of  junction.  The  new 
opening  from  the  colon  admitted  the  little  finger,  and  was  surrounded  by  a 
prominent  ridge  of  mucous  membrane,  which  resembled  the  ileo-caecal  valve. 

Experiment  78.  Dog,  weight  fourteen  pounds.  Division  of  ileum  a  few 
inches  above  ileo-caecal  valve,  distal  end  closed  by  invagination,  and  three 
stitches  of  continued  suture.  Implantation  of  proximal  end  into  colon  by 
rubber  ring  and  two  catgut  invagination  sutures.  Over  the  junction  of  the 
two  intestines  an  omental  flap  was  placed  which  was  retained  by  a  catgut 
suture.  The  animal  showed  no  unfavorable  symptoms  and  was  killed  twenty- 
three  days  after  operation.  Omental  flap  retained  and  firmly  adherent 
throughout.  Point  of  implantation  three  inches  above  caecum;  union  between 
the  two  intestines  firm  throughout.  New  opening  corresponded  in  size  to  the 
lumen  of  the  ileum,  and  was  surrounded  by  a  prominent  ridge  of  mucous 
membrane  which  appeared  to  be  derived  from  the  invaginated  portion  of  the 
ileum. 


192  INTESTINAL  SURGERY. 

Experiment  79.  Ileum  divided  a  few  inches  above  ileo-csecal  region,  and 
after  closure  of  the  distal,  the  proximal  end  was  implanted  into  the  colon  in 
the  usual  manner  by  a  rubber  ring  and  two  invagination  sutures  of  catgut. 
Animal  died  on  third  day  after  operation.  Wound  partially  united;  a  con- 
siderable quantity  of  sero-sanguinolent  fluid  in  the  abdominal  cavity.  Ileum 
almost  completely  separated  from  colon,  and  the  portion  which  had  been 
invaginated  showed  signs  of  gangrene.  Rubber  ring  had  disappeared;  death 
from  perforative  peritonitis.  In  this  case  we  have  reason  to  believe  that  the 
rubber  ring  which  was  used  was  too  large,  and  that  the  gangrene  and  separa- 
tion was  due  to  injurious  pressure. 

b.    Ileo-Oolostomy  by  Lateral  Apposition. 

Anastomosis  by  this  method  was  made  after  producing  an 
intestinal  obstruction  of  some  kind  at  or  near  the  ileo-csecal  region, 
and  then  by  bringing  the  ileum  above  the  seat  of  obstruction  in 
communication  with  the  colon  below  the  pomt  of  obstruction,  by 
making  an  incision  an  inch  and  a  half  to  two  inches  in  length  in  both 
intestines  at  a  point  opposite  the  mesenteric  attachments,  and  unit- 
ing the  wounds  either  by  a  double  row  of  sutures  or  perforated 
decalcified  bone  discs.  The  first  experiments  were  all  made  by 
suturing  but,  as  in  circular  enterorrhaphy,  it  was  found  by  experi- 
ence that  perforation  not  infrequently  occurred  along  the  track  of 
one  of  the  sutures,  in  some  instances  several  days  after  the  operation, 
at  a  time  when  union  had  taken  place  by  firm  adhesions.  These 
unfavorable  results  led  to  the  use  of  the  approximation  discs. 

Experiment  80.  Dog,  weight  twenty-five  pounds.  The  ileum  was  with- 
drawn from  the  abdomen  through  an  incision  in  the  linea  alba,  and  having 
emptied  a  loop  of  its  contents,  acute  flexion  was  made  just  above  the  ileo-cgecal 
region  by  approximating  the  serous  surfaces  of  the  convex  side  for  a  inch  and 
a  half  by  five  catgut  sutures.  Two  longitudinal  incisions  of  equal  size  were 
made,  one  in  the  ileum  six  inches  above  the  flexion,  and  the  other  in  the 
ascending  colon  three  inches  above  the  caecum.  The  visceral  wounds  were 
carefully  united  by  Czerny-Lembert  sutures,  using  silk  for  the  deep  interrupted 
sutures,  and  fine  catgut  for  the  superficial  continued  sutures.  No  untoward 
symptoms  were  observed  after  the  operation;  appetite  remained  unimpaired, 
and  fgecal  discharges  were  normal.  The  dog  was  killed  thirty-seven  days  after 
operation.  Animal  well  nourished.  No  evidences  of  peritonitis.  Bowel  above 
point  of  obstruction  nearly  empty,  and  somewhat  contracted  as  far  as  the  new 
opening.  Flexion  permeable  to  a  stream  of  water.  Slight  omental  adhesions 
to  bowel  at  site  of  operation ;  union  firm  throughout.  Lumina  of  non-excluded 
portion  of  bowel  normal  in  size  above  and  below  the  flexion.  Serous  surfaces 
at  point  of  junction  appeared  perfect  and  continuous.  On  slitting  open  the 
colon  opposite  the  new  opening,  its  outlines  were  seen  to  be  marked  by  a 
prominent  ridge  of  mucous  membrane  to  which  a  number  of  the  deep  sutures 


ILEO-COLOSTOMY.  193 

remained  attached.  The  opening  was  large  enough  to  admit  the  tip  of  the 
middle  finger.  The  excluded  portion  of  the  colon  and  the  caecum  were  some- 
what contracted  and  atrophic,  and  contained  only  a  very  small  quantity  of 
faecal  matter. 

Experiment  81.  Medium-sized  cat.  About  two  inches  of  the  ileum  were 
invaginated  into  the  colon  through  the  ileo-c^cal  valve,  and  the  intussusceptum 
stitched  to  the  neck  of  the  intussuscipiens  by  two  fine  catgut  sutures. 
Continuity  of  the  intestinal  canal  restored  by  incising  the  ileum  above  the 
obstruction,  and  the  ascending  colon  below  the  free  extremity  of  the  intussus- 
ceptum, and  uniting  the  wounds  by  a  double  row  of  sutures.  The  invagination 
caused  no  serious  disturbance,  and  the  animal  remained  in  good  health  and 
was  in  excellent  condition  at  the  time  of  killing,  one-hundred  and  sixty-two 
days  after  operation.  A  number  of  adhesions  between  the  folds  of  the  intes- 
tines near  the  site  of  operation.  At  point  of  juncture  of  the  two  intestines  the 
peritoneal  surface  presented  a  glistening  and  continuous  surface.  New  open- 
ing an  inch  and  a  half  in  length,  oval  in  outline  and  located  five  inches  above 
the  ileo-CEecal  region.  Two  inches  below  the  opening  the  invagination  remained 
in  the  shape  of  a  circular  thickening  of  the  bowel  with  a  narrowing  of  its 
lumen  to  more  than  one-half  of  its  normal  size.  A  close  inspection  of  the 
specimen  showed  that  no  gangrene  had  occurred,  but  that  the  intussusceptum 
had  undergone  atrophy.  A  stream  of  water  passing  along  the  ileum  in  a 
downward  direction  escaped  through  the  invaginated  portion  and  through  the 
new  opening,  the  stream  from  the  latter  being  at  least  three  times  larger 
than  the  one  through  the  intussusceptum.  Excluded  portion  of  ileum  and 
colon  empty  and  very  much  atrophied  and  contracted.  Below  the  new  open- 
ing the  colon  and  rectum  contained  normal  faeces  in  considerable  quantity. 

Experiment  82.  Young  cat.  Ileo-caecal  invagination ;  length  of  intussus- 
ceptum four  inches.  In  order  to  prevent  spontaneous  disinvagination  the 
bowel  was  fixed  in  its  position  by  two  fine  catgut  sutures.  Ileo-colostomy 
below  the  lower  end  of  the  intussusceptum  by  lateral  apposition  and  suturing. 
Animal  died  on  the  fourth  day  after  operation.  Abdominal  wound  united. 
Diffuse  peritonitis  from  perforation  at  site  of  suturing.  Length  of  intussus- 
ceptum reduced  from  four  inches  to  two  inches  and  a  half.  It  was  found 
impossible  to  effect  reduction  by  traction  on  account  of  firm  adhesions  at  neck 
of  intussuscipiens.     No  gangrene. 

Experiment  83.  Adult,  large  dog.  Intestinal  obstruction  was  produced 
by  making  two  sharp  flexions  near  the  ileo-caecal  region  by  folding  the  bowel 
on  its  side  and  fixing  it  in  this  position  by  fine  catgut  sutures;  the  apices  of 
the  flexions  were  sutured  together  so  as  to  render  the  obstruction  more  com- 
plete. Intestinal  anastomosis  was  established  by  lateral  apposition  and 
suturing.  Physical  condition  of  dog  remained  good  throughout;  appetite  and 
evacuations  normal.  Killed  thirty-one  days  after  operation.  No  peritonitis; 
a  number  of  omental  adhesions  at  point  of  operation.  Flexions  quite  sharp, 
rendering  the  bowel  nearly,  if  not  completely,  impermeable  at  this  point. 
Perfect  union  between  bowels,  with  some  thickening  of  their  walls  by  inflam- 
matory exudation.  New  opening  oval  in  shape,  an  inch  and  a  half  in  length, 
13 


194  INTESTINAL  SURGERY. 

a  few  of  the  deep  sutures  still  remaining  attached  to  its  margins.     Excluded 
portion  of  bowel  empty  and  somewhat  atrophic. 

Experiment  84.  Dog,  weight  thirteen  pounds.  Obstruction  of  the  bowels 
made  by  an  acute  flexion  four  inches  above  the  ileo-csecal  region,  retained  by 
four  catgut  sutures.  Intestinal  anastomosis  by  an  opening  an  inch  and  a 
half  in  length,  which  brought  into  communication  the  ileum  above  the  obstruc- 
tion and  the  descending  colon.  The  animal  showed  no  untoward  symptoms,  and 
was  killed  forty-one  days  after  operation.  A  number  of  intestinal  folds 
agglutinated  by  adhesions;  no  evidences  of  diffuse  peritonitis.  Where  the 
flexion  had  been  made  the  loop  of  intestine  was  connected  by  a  broad  band  of 
adhesion  which  gave  to  the  bowel  a  horse-shoe  shaped  appearance.  Intestine 
below  the  seat  of  flexion  contained  a  small  amount  of  hardened  faeces.  Colon 
and  caecum  above  the  new  opening  nearly  empty  and  greatly  contracted. 
Line  of  suturing  somewhat  thickened.  New  opening  oval  in  outline  and 
about  an  inch  in  length,  surrounded  by  a  corrugated  elevation  of  mucous 
membrane.  A  streafn  of  water  passed  through  the  bowel  from  above  down- 
ward readily  escaped  through  the  new  opening,  while  only  a  small  stream  could 
be  forced  through  the  flexion. 

Experiment  85.  Dog,  weight  twenty-seven  pounds.  A  volvulus  was  made 
six  inches  above  the  ileo-caecal  region  by  rotating  an  empty  loop  of  the 
intestine  once  around  its  axis,  and  fixing  it  in  this  position  by  three  catgut 
sutures.  Intestinal  anastomosis  between  the  ileum  above  the  volvulus  and  the 
descending  colon  by  lateral  apposition  and  suturing.  For  four  days  after  the 
operation  the  evacuations  from  the  bowels  contained  blood;  after  this  time 
the  stools  were  normal.  Dog  in  excellent  condition  when  killed  thirty-one 
days  after  operation.  No  signs  of  diffuse  peritonitis.  The  portion  of  bowel 
which  constituted  the  volvulus  adherent,  contracted  and  empty.  Water  could 
be  readily  forced  through  this  part  of  the  bowel.  Cfecum  and  colon  above 
new  opening  empty  and  contracted.  Size  of  new  opening  larger  than  the 
lumen  of  the  ileum,  its  margins  surrounded  by  a  prominent  ridge  of  mucous 
membrane  to  which  a  few  of  the  deep  sutures  still  remained  attached.  In  this 
experiment  nearly  the  entire  colon  was  excluded,  consequently  the  faecal  dis- 
charges were  quite  frequent  and  fluid  or  semi-fluid  in  consistence. 

Experiment  86.  Dog,  weight  seventeen  pounds.  Two  inches  of  the  Ueum 
were  invaginated  into  the  caecum.  Ileo-colostomy  by  uniting  the  ileum  with 
the  transverse  colon  by  suturing.  The  animal  appeared  quite  ill  after  the 
operation  and  died  on  the  fifth  day  after  having  manifested  well-marked 
symptoms  of  perforative  peritonitis.  Abdominal  wound  not  united.  Only 
partial  union  between  the  intestines  at  point  of  junction.  Diffuse  septic 
peritonitis  from  perforation. 

Remakks. — In  at  least  two  experiments  which  are  not  here 
reported,  the  animals  died  of  shock  a  few  houi's  after  operation.  In 
a  number  of  other  experiments  the  operation  was  followed  by  more 
or  less  shock,  but  the  animals,  without  receiving  any  special  treat- 
ment, rallied  after  six  to  twelve  hours.      The  symptoms  referable  to 


ILEO-COLOSTOMY.  195 

the  immediate  effects  of  the  operation  were  due  to  the  length  of 
time  required  in  applying  a  double  row  of  sutures  in  uniting  the 
visceral  wounds,  a  step  in  the  operation  which  always  required  from 
thirty  minutes  to  an  hour.  These  experiments  only  corroborate  the 
statement  previously  made  that  the  excluded  portion  of  the  intestinal 
canal,  including  the  obstruction,  does  not  become  the  seat  of  faecal 
accumulation,  but  undergoes  atrophy  after  free  intestinal  anastomosis 
has  been  established  between  the  intestine  above  and  below  the  seat 
of  obstruction.  Experiments  Nos.  70  and  71  furnish  most  striking 
proof  that  the  danger  of  gangrene  in  cases  of  invagination  is  greatly 
diminished  by  establishing  an  early  intestinal  anastomosis,  as  when 
this  is  done  the  violent  peristalsis  is  promptly  arrested  by  furnishing 
a  new  outlet  to  the  intestinal  contents  ;  at  the  same  time,  the  serious 
consequences  resulting  from  pressure  and  distention  above  the 
obstruction  are  likewise  promptly  averted.  In  cases  of  intestinal 
anastomosis  where  nearly  the  entire  colon  has  been  excluded,  the 
fluid  contents  of  the  small  intestines  reach  the  rectum  at  once,  and 
cause  frequent  fluid  faecal  discharges,  an  occurrence  which  does  not 
appear  to  impair  the  general  health  of  the  animal.  The  new  open- 
ing should  be  made  of  adequate  size,  so  that  its  lumen  will  at  least 
correspond  to  the  lumen  of  the  bowel  above  the  obstruction. 

c.     Ileo-Colostoiny  by  Perforated  Approxiraation  Discs. 

Experiment  87.  Dog,  weight  twenty  pounds.  The  ileum  was  completely 
divided  three  inches  above  the  ileo-caecal  region,  both  ends  closed  by  invagi- 
nation and  three  stitches  of  the  continued  suture.  A  communication  was 
established  between  the  proximal  extremity  and  the  colon,  by  making  an 
incision  into  the  ileum  on  convex  side  near  the  closed  end  and  introducing 
through  this  opening  a  perforated  decalcified  bone  plate.  A  similar  opening 
was  made  into  the  ascending  colon  opposite  its  mesenteric  attachment, 
through  which  a  perforated  plate  of  wood  was  introduced.  To  each  plate 
were  tied  four  catgut  sutures.  The  lateral  sutures  were  passed  through  the 
margins  of  the  wound.  After  the  plates  and  sutures  were  in  place  the  wounds 
were  brought  in  contact  and  the  four  sutures  tied,  which  coaptated  the  serous 
surfaces  of  both  bowels  over  an  area  corresponding  to  the  size  of  the  plates. 
The  animal  remained  apparently  well  for  two  days,  when  symptoms  of 
peritonitis  set  in  and  death  occurred  five  days  after  operation.  Diffuse 
peritonitis.  Union  at  point  of  operation  incomplete,  which  resulted  in  a 
perforation.  Discs  had  disappeared.  As  the  catgut  sutures  were  quite  fine  it 
is  more  than  probable  that  partial  separation  of  the  plates  occurred  before 
adhesions  had  taken  place  between  the  serous  surfaces  of  the  coaptated  bow- 
els, which  resulted  in  perforation  and  death  from  dififuse  septic  peritonitis. 


196  INTESTINAL  SURGERY. 

Experiment  88.  Dog,  weight  fifteen  pounds.  Invagination  of  colon  into 
colon  to  the  extent  of  two  inches.  Intestinal  anastomosis  by  making  an  ileo- 
colostomy  by  lateral  apposition  of  the  ileum  to  colon  below  invagination, 
using  perforated  hard  rubber  plates  which  were  tied  together  by  four  catgut 
sutures,  the  lateral  sutures  being  passed  through  the,  margins  of  the  wound. 
After  tying  the  sutures  it  was  found  that  at  one  point  the  margins  of  the 
wound  showed  a  tendency  to  evert,  consequently  a  fine  catgut  suture  was 
passed  through  the  peritoneum  only  and  tied.  The  animal  did  not  appear 
bright  the  day  after  the  operation,  but  subsequently  showed  no  signs  of 
suffering;  killed  twenty-four  days  after  operation.  Abdominal  wound  firmly 
united.  Omentum  adherent  to  wound  and  at  point  of  operation.  The  in- 
vagination was  partially  reduced.  The  bowel  at  this  point  was  curved  in  the 
shape  of  a  horse-shoe,  but  permeable  to  a  stream  of  water.  Excluded  portion 
of  colon  tortuous  and  atrophic.  Caecum  contained  a  small  quantity  of  fluid 
fsBces.  Plates  could  not  be  found.  New  opening  sufficiently  large  for  free 
passage  of  intestinal  contents. 

Experiment  89.  Dog,  weight  fifteen  pounds.  Ileum  divided  transversely 
fifteen  inches  above  the  ileo-csecal  region;  both  ends  closed  in  the  usual 
manner.  Ileum  and  colon  approximated  by  decalcified  perforated  bone 
plates  which  were  tied  together  by  four  catgut  sutures,  the  lateral  ones 
transfixing  the  margins  of  the  wound.  On  the  second  day  the  evacuation  from 
the  bowels  contained  traces  of  blood.  Animal  killed  eighteen  days  after  opera- 
tion. Abdominal  wound  completely  healed.  Omentum  adherent  to  wound. 
Numerous  adhesions  between  the  intestinal  folds.  Proximal  blind  end  of 
ileum  had  been  changed  into  a  pouch-like  form  and  contained  a  mass  of  hair 
and  fragments  of  bone.  One  very  sharp  spiculum  of  bone  had  nearly  perfo- 
rated the  intestine.  New  opening  corresponded  in  size  to  the  lumen  of  the 
ileum. 

Remarks. — The  operations  of  lateral  apposition  of  ileum  to  colon 
by  perforated  approximation  discs,  have  shown  that  it  is  unsafe  to 
rely  upon  catgut  as  a  suturing  material,  as  when  fine  catgut  is  used 
coaptation  is  not  maintained  for  a  suificient  length  of  time  for 
adhesions  to  take  place,  and  coarse  catgut  when  tied  interferes 
with  accurate  approximation,  as  the  knots  after  tying  mechanically 
separate  the  serous  surfaces.  It  is  advisable  to  use  removable  plates 
and  to  tie  with  silk.  The  results  of  ileo-colostomy  made  by  approxi- 
mation discs  have  not  been  as  favorable  as  after  jejuno-ileostomy  or 
ileo-ileostomy,  and  in  repeating  the  operation  on  man  it  would  be 
indicated,  after  bringing  the  intestines  in  apposition  by  tying  the 
four  sutures,  to  apply  a  number  of  superficial  sutures  for  the  pur- 
pose of  still  further  guarding  against  the  escape  of  gas  or  fluid 
contents  into  the  peritoneal  cavity.  The  plates  when  properly  fixed 
in  their  places  and  tied  together  with  sufficient  firmness,  not  only 


ILEO-RECTOSTOMY.  197 

coaptate  an  extensive  area  of  serous  surfaces,  but  they  at  the  same 
time  secure  perfect  rest  for  the  parts  which  it  is  intended  to  unite, 
until  firm  adhesions  have  formed. 

4.    Ileo-Rectostomy. 

In  cases  of  intestinal  obstruction  due  to  inoperable  conditions 
low  down  in  the  colon,  it  becomes  necessary  to  establish  an  intestinal 
anastomosis  between  the  ileum  and  the  rectum,  in  order  to  avert  the 
necessity  of  making  an  artificial  anus;  in  other  words,  to  make  an 
ileo-rectostomy.  The  operation  can  be  made  in  the  same  way  as 
establishing  a  communication  between  the  ileum  and  the  colon  by 
lateral  implantation,  by  lateral  apposition  and  double  suturing,  or 
by  lateral  apposition  by  perforated  decalcified  bone  plates.  The 
operation  is,  however,  more  difficult  because  the  rectum  is  not  as 
accessible  as  the  colon,  and  from  the  greater  vascularity  of  the  gut, 
the  incision  is  more  liable  to  give  rise  to  troublesome  haemorrhage. 
While  the  slight  haemorrhage  from  an  incision  into  the  small  intes- 
tines and  the  colon  is  usually  promptly  arrested  by  suturing,  or 
compression  by  the  approximation  discs,  the  bleeding  from  a  wound 
of  the  upper  portion  of  the  rectum  not  infrequently  requires  the 
application  of  one  or  more  catgut  ligatures  before  it  is  safe  to  unite 
the  wounds.  During  the  operation  traction  must  be  made  upon  the 
rectum  in  an  upward  direction  so  as  to  lift  the  upper  portion  of 
the  bowel  out  of  the  pelvis.  In  both  of  the  experiments  described 
below,  the  wounds  were  united  by  Czerny-Lembert  sutures. 

Experiment  90.  Dog,  weight  ninety  pounds.  Invagination  of  colon  into 
colon  for  two  inches  and  suturing  of  intussusceptum  to  neck  of  intussuscipiens 
by  four  fine  silk  sutures  to  prevent  spontaneous  disinvagination.  Ileum 
incised  in  a  parallel  direction  for  an  inch  and  a  half  on  convex  side,  and  this 
wound  united  with  a  similar  incision  in  the  rectum  on  its  anterior  surface  by 
a  double  row  of  sutures.  For  the  purpose  of  immobilizing  the  sutured  intes- 
tines an  additional  fine  catgut  suture  was  applied  above  and  below  the  place 
of  suturing,  embracing  only  the  peritoneal  and  muscular  coats  of  the  intes- 
tines. On  the  third,  fourth,  and  fifth  days  the  faecal  discharges  contained 
blood  and  mucus.  On  the  sixth  day  the  abdominal  wound  partially  opened, 
and  a  considerable  quantity  of  sero-purulent  fluid  escaped.  Death  seven  days 
after  operation.  Abdominal  wound  not  united.  Diffuse  purulent  peritonitis. 
Numerous  intestinal  adhesions.  Invagination  retained;  adhesions  between 
the  intussusceptum  and  intussuscipiens;  no  gangrene;  perforation  at  point  of 
operation. 

Experiment  91.  Cat,  weight  seven  pounds.  Heo-rectostomy  by  lateral 
implantation.     The  ileum  was  cut  across  transversely  an  inch  above  the  ileo- 


198  INTESTINAL  SURGERY. 

caecal  valve,  and  the  distal  end  closed  by  invagination  and  three  stitches  of 
the  continued  suture.  The  proximal  end  was  transplanted  into  a  longitudinal 
incision  09  the  anterior  surface  of  the  upper  portion  of  the  rectum  by  Czerny- 
Lembert  sutures.  With  the  exception  of  an  occasional  slight  rise  in  tempera- 
ture no  serious  disturbances  were  observed  during  the  progress  of  the  case. 
The  evacuation  of  the  small  intestines  directly  into  the  rectum  appeared  to 
increase  the  peristaltic  action  of  the  rectum,  as  the  faecal  discharges  were  fluid 
and  frequent.  Animal  killed  twenty  days  after  operation.  Abdominal  wound 
completely  united.  No  peritonitis.  A  few  folds  of  the  small  intestines  and 
the  omentum  adherent  to  the  wound.  Insertion  of  ileum  into  rectum  in  an 
oblique  direction;  union  at  point  of  junction  complete  throughout;  intestinal 
coats  at  this  point  somewhat  thickened.  Peritoneal  surface  smooth  and  con- 
tinuous from  one  bowel  to  the  other.  New  ileo-rectal  opening  corresponded  in 
size  to  the  lumen  of  the  ileum;  margins  of  this  opening  consisted  of  a  ridge  of 
mucous  membrane  to  which  a  row  of  the  deep  sutures  remained  attached. 
Excluded  portion  of  large  intestine  empty  and  contracted.  Rectum  contained 
a  small  quantity  of  fluid  faeces. 

5.     Colo-Rectostomy. 

Among  the  many  possibilities  in  the  operative  treatment  of 
intestinal  obstruction,  a  condition  might  be  met  with  where  the  seat 
of  obstruction  is  located  low  down  in  the  colon,  perhaps  in  the  sig- 
moid flexure,  and  where  it  might  be  impossible  or  impracticable  to 
remove  the  cause  of  obstruction,  and  where  it  becomes  necessary 
to  restore  the  continuity  of  the  intestinal  canal  by  establishing  a 
communication  between  the  permeable  portion  of  the  colon  and  the 
rectum.  Such  an  anastomosis  can  be  made,  as  in  ileo-colostomy,  by 
lateral  implantation,  lateral  apposition  by  perforated  approximation 
plates,  or  by  double  suturing.  For  want  of  time  only  one  experiment 
was  made,  and  although  the  animal  died  from  the  immediate  effects 
of  the  operation,  the  local  conditions  at  the  site  of  operation  found 
after  death  showed  that  colo-rectostomy  in  selected  cases  is  not  only 
a  justifiable  and  feasible  operation,  but  whenever  it  can  be  done,  that 
it  is  always  preferable  to  the  formation  of  an  artificial  anus.  As  the 
operation  by  lateral  apposition  requires  much  less  time  than  lateral 
implantation,  it  should  be  preferred  to  the  latter  procedure,  and 
should  be  done  by  perforated  approximation  discs  and  a  few  super- 
ficial sutures. 

Experiment  92.  Medium-sized  cat.  Incision  through  the  linea  alba ;  colon 
cut  transversely  in  the  middle  third  and  the  distal  portion,  and  the  rectum 
cleared  of  its  contents  by  injecting  a  stream  of  warm  water  from  the  cut  end 
downward,  a  procedure  which  could  only  be  well  accomplished  after  forcible 


ADHESION  EXPERIMENTS.  l99 

dilatation  of  the  sphincter  ani  muscles.  The  distal  end  was  closed  in  the 
nsual  manner.  The  rectum  was  drawn  upward  and  an  incision  made  into  its 
anterior  wall  large  enough  to  correspond  with  the  lumen  of  the  colon.  Into 
this  opening  the  proximal  end  of  the  colon  was  implanted  by  two  rows  of 
sutures.  During  the  latter  part  of  the  operation,  which  lasted  over  an  hour, 
the  animal  was  seized  by  convulsions  which  continued  for  several  hours,  and 
finally  subsided  under  the  administration  of  whisky  given  hypodermically. 
The  symptoms  of  shock,  however,  continued  and  death  occurred  thirty-six 
hours  after  operation.  Numerous  omental  adhesions;  closed  end  of  bowel 
congested;  peritoneal  surfaces  adherent;  colon  and  rectum  at  point  of 
implantation  adherent. 

Remakes. — In  cases  where  the  obstruction  is  located  some  dis- 
tance from  the  rectum,  where  it  would  be  impossible  to  approximate 
the  permeable  portion  of  the  colon  with  the  rectum,  the  entire  colon 
must  be  excluded  and  the  continuity  of  the  intestinal  canal  restored 
by  ileo- colostomy  or  ileo-rectostomy.  In  all  cases  of  intestinal 
anastomosis  where  the  communication  is  made  in  the  lower  portion 
of  the  colon  or  the  rectum,  the  sphincters  of  the  anus  should  be 
rendered  temporarily  incompetent  by  stretching,  for  the  purpose  of 
guarding  against  over- distention  of  this  part  of  the  bowel  during 
the  time  required  for  the  healing  process  between  the  united 
intestines. 

T.    Adhesion  Experiments. 

In  works  on  abdominal  surgery  we  invariably  meet  with  the 
assertion  that  serous  surfaces  brought  into  apposition  by  suturing 
unite  after  a  few  hours.  Isolated  experiments  and  the  results  of 
post-mortem  examinations  have  given  rise  to  the  general  belief  that 
serous  surfaces  so  united  will  become  firmly  adherent  in  a  very  short 
time;  but  the  question  concerning  the  exact  time  for  adhesion  to 
take  place,  and  for  the  definitive  healing  to  be  complete,  can  only  be 
determined  by  experiments  made  for  this  special  purpose.  The 
following  experiments  were  made  with  a  view  of  ascertaining  the 
exact  time  which  is  requisite  for  adhesions  and  definitive  healing 
between  approximated  serous  surfaces  to  take  place,  and  likewise  to 
study  the  effects  of  local  conditions  which  would  hasten  or  retard 
these  processes.  It  is  quite  important  to  make  a  distinction  between 
the  terms  "adhesion"  and  "healing."  Adhesion  precedes  the  pro- 
cess of  definitive  healing,  but  implies  simply  the  presence  of  an 
adhesive  or  cement  substance  between  the  serous  surfaces,  which 
mechanically  agglutinates  the  parts ;  while  definitive  healing  includes 


200  INTESTINAL  SURGERY. 

all  the  processes  which  take  place  during  cicatrization.  In  intestinal 
surgery  this  distinction  has  an  important  practical  bearing,  as  per- 
foration may  take  place  as  long  as  the  serous  surfaces  are  simply 
held  together  by  adhesions,  while  such  an  occurrence  is  beyond  the 
reach  of  all  possibilities  after  the  approximated  surfaces  have 
become  united  by  living  organized  tissue.  Adhesions  between 
serous  surfaces  take  place  by  the  exudation  of  plastic  lymph,  which 
acts  the  part  of  a  cement  material;  while  on  the  other  hand,  the 
process  of  definitive  healing  is  initiated  by  cell -proliferation  from 
the  pre-existing  endothelial  and  connective  tissue  cells,  and  the  for- 
mation of  a  network  of  new  blood-vessels  springing  from  each  of  the 
eoaptated  granulating  surfaces.  The  processes  are  the  same  as  we 
observe  within  blood-vessels  during  cicatrization  after  ligature.  In 
suturing  an  intestinal  wound,  or  in  making  a  circular  enterorrhaphy, 
it  has  always  heretofore  been  deemed  necessary  not  to  injure  the 
peritoneum  unnecessarily,  for  fear  that  such  injuries  would  result 
deleteriously  by  interfering  with  the  prompt  union  between  the 
sutured  surfaces. 

It  is  a  well  known  fact  in  surgery  that  approximation  of  intact 
serous  surfaces  does  not  result  in  the  formation  of  adhesions. 
When  the  surgeon  desires  to  secure  union  between  serous  surfaces 
he  resorts  to  mechanical  irritation  for  the  purpose  of  inducing  a 
circumscribed  plastic  peritonitis,  which  invariably  results  in  adhe- 
sions and  the  obliteration  of  the  serous  space.  Reasoning  from 
this  analogy,  I  was  induced  to  study  the  effects  of  traumatic  and 
chemical  irritation  in  hastening  adhesions  and  cicatrization  between 
apposed  serous  surfaces.  In  most  of  these  experiments  the  serous 
surfaces  in  the  different  operations  were  held  in  contact  by  perfor- 
ated approximation  plates,  and  in  case  artificial  means  were 
employed  to  expedite  the  healing  process,  the  fact  is  mentioned, 
and  the  result  of  such  modification  noted.  The  animals  operated 
on  were  all  dogs. 

I.     Traumatic  Irritation  of  Serous  Surfaces. 

Time,  Six  Houbs. 

Experiment  93.  The  ileum  was  divided  near  the  middle,  and  both  ends 
closed  by  invagination  and  the  continued  suture.  Ileo-ileostomy  was  made 
at  two  points,  making  two  openings  of  communication.  No  suturing.  Parts 
kept  in  apposition  by  perforated  decalcified  bone  plates.  To  compare  the 
effect  of  traumatic  irritation  of  the  peritoneum  in  the  reparative  process 


TRAUMATIC  IRRITATION   OF  SEROUS  SURFACES.  201 

with  the  intact  serons  surface,  the  peritoneal  surfaces  at  one  point  of  opera- 
tion designated  as  the  upper,  were  scarified  with  the  point  of  a  needle  over  an 
area  corresponding  to  the  size  of  the  bone  discs,  the  scratches  being  made 
sufficiently  deep  to  penetrate  the  entire  thickness  of  the  peritoneum.  The 
scarifications  were  made  in  a  longitudinal  and  transverse  direction,  mapping 
out  the  serous  surfaces  into  small  squares.  Only  slight  oozing  followed  this 
procedure.  The  serous  surfaces  between  the  plates  at  No.  1,  where  no  scarifi- 
cation was  made,  was  found  slightly  adherent  by  a  scanty  deposit  of  plastic 
lymph.  At  No.  2,  where  scarifications  had  been  done,  the  amount  of  plastic 
lymph  was  greater  and  stained  by  blood,  and  the  adhesions  much  firmer. 

Time,  Twelvk  Houes. 

Experiment  94.  In  this  experiment  the  bowel  was  not  interrupted  by 
division,  but  two  adjacent  coils  of  the  ileum  were  united  by  making  an  ileo- 
ileostomy  by  perforated  decalcified  bone  plates,  the  plates  holding  the  parts 
perfectly  in  apposition ;  a  slight  tumefaction  of  the  intestinal  walls  made  the 
coaptation  more  secure.  Coaptated  serous  surfaces  very  vascular,  covered 
with  a  thin  layer  of  plastic  lymph  which  had  agglutinated  the  folds  of  the 
intestine  brought  in  contact. 

Experiment  95.  Bowel  not  divided,  but  two  adjoining  loops  of  the  ileum 
united  by  making  a  double  ileo-ileostomy  by  perforated  approximation  discs, 
the  two  communicating  openings  about  six  inches  apart.  At  one  point  of 
operation,  designated  as  No.  2,  serous  surfaces  freely  scarified.  At  both 
points  the  adhesions  were  perfect  throughout,  but  where  scarification  was 
made  they  were  notably  firmer. 

Exx>eriment  96.  In  this  experiment  a  gastro-enterostomy  and  an  ileo- 
ileostomy  were  made  at  the  same  time  and  on  the  same  animal.  In  both 
operations  the  parts  were  coaptated  by  perforated  decalcified  bone  plates. 
Scarification  of  peritoneal  surfaces  at  both  places.  The  adhesions  between 
the  anterior  surface  of  the  stomach  and  upper  portion  of  jejunum  were 
uniform  throughout,  over  the  whole  surface,  kept  in  contact  by  the  plates. 
There  was  no  leakage  on  distending  the  stomach  and  intestine  forcibly  by 
water.  The  adhesions  between  the  folds  of  the  ileum  at  point  of  approxima- 
tion were,  if  anything,  firmer  than  between  stomach  and  jejunum.  The 
decalcified  bone  plate  in  the  interior  of  the  stomach  was  softened  more  than 

those  in  the  intestine. 

Time,  Eighteen  Houks. 

Experiment  97.  Gastro-enterostomy  by  perforated  decalcified  bone 
plates;  communication  made  between  stomach  and  upper  portion  of  jejunum; 
no  scarification.  Agglutination  quite  firm,  so  that  forcible  distention  of 
stomach  and  bowel  caused  no  leakage.  New  opening  sufficiently  large  to 
admit  middle  finger,  and  apparently  lined  throughout  by  mucous  membrane. 
Plate  in  stomach  very  much  softened  and  on  the  verge  of  becoming  detached. 
On  forcibly  separating  the  adhesions  the  serous  surfaces  were  found  to  be 
cemented  together  by  a  thin  layer  of  plastic  lymph,  and  after  scraping  this 
away  they  appeared  vascular  and  rough,  as  though  completely  deprived  of  the 
endothelial  covering. 


202  INTESTINAL  SURGERY. 

Time,  Twenty-foub  Houbs. 

Experiment  98.  Triple  ileo-ileostomy  -without  division  of  the  bowel ;  the 
operations  were  numbered  1,  2,  3,  respectively.  Coaptation  by  approxima- 
tion discs  of  decalcified  bone.  Communicating  openings  about  six  inches 
apart.  In  No.  1  no  scarification.  No.  2,  scarification  of  one  loop  only.  No. 
3,  scarification  of  both  serous  surfaces.  After  twenty-four  hours  the  result 
was  as  follows  : 

No.  1.     Lymph  scanty;  adhesions  not  very  firm. 

No.  2.     Lymph  more  plentiful ;  adhesions  firmer. 

No.  3.  Lymph  more  abundant  than  in  No.  2,  and  mixed  with  a  fine 
stratum  of  coagulated  blood  ;  adhesions  also  firmer.  The  adhesions  increase 
in  firmness  in  the  order  1,  2,  3. 

Ex2Jeriment  99.  Double  gastro-enterostomy  by  perforated  decalcified 
bone  plates.  The  communicating  openings,  one  near  the  pyloric,  and  the  other 
near  the  cardiac  extremity  of  the  stomach,  were  made  between  the  anterior 
surface  of  the  stomach,  and  the  upper  portion  of  the  Jejunum.  In  operation 
No.  1,  the  intact  serous  surfaces  near  the  pylorus  were  brought  in  contact, 
while  in  the  second  operation  both  the  stomach  and  bowel  were  scarified.  At 
the  post-mortem,  it  was  found  that  the  adhesions  at  both  places  were  of 
sufficient  firmness  to  prevent  leakage  under  pressure.  In  No.  2,  adhesions 
firmer  and  the  inflammatory  infiltration  more  marked  than  in  No.  1.  Plates 
in  stomach  much  softened,  but  remain  m  situ.  Openings  lined  throughout 
by  mucous  membrane  and  sufficiently  large  to  admit  the  index  finger. 

Experiment  100.  Ileo-colostomy  by  lateral  apposition  and  fixation  by 
perforated  approximation  discs.  Lower  portion  of  ileum  united  with  the 
ascending  colon.  No  scarification  ;  bowels  lightly  agglutinated  throughout 
by  a  very  thin  layer  of  plastic  lymph  ;  adhesions,  however,  could  be  easily 
separated,  and  where  this  is  done  the  peritoneal  surface  appeared  denuded  of 
endothelial  cells,  and  very  vascular  with  new  vessels  along  the  outer  margin 
of  the  surface  of  approximation. 

Time,  Fobty-eight  Houbs. 

Experiment  101.  Double  gastro-enterostomy.  The  communicating  open- 
ings were  between  the  anterior  surface  of  the  stomach  and  the  duodenum,  and 
the  posterior  surface  of  the  stomach  and  the  upper  portion  of  the  jejunum. 
In  the  posterior  operation  the  intact  serous  surfaces  were  brought  in  contact, 
while  in  the  anterior,  the  peritoneal  surfaces  of  the  stomach  and  duodenum 
were  scarified.  In  both  operations  perforated  decalcified  bone  plates  were 
used.  Adhesions  between  posterior  surface  of  stomach  and  bowel  uniform 
throughout,  but  easily  broken  down;  the  peritoneal  surfaces  injected  and 
apparently  deprived  of  their  endothelial  covering.  The  anterior  operation 
resulted  in  the  formation  of  firm  adhesions,  the  products  of  exudation  and 
tissue  proliferation  being  supplied  with  new  vessels,  the  circumscribed  plastic 
peritonitis  being  much  more  advanced  than  at  the  site  of  the  posterior 
operation. 


CHEMICAL  IRRITATION   OF  SEROUS  SURFACES.  203 

Experiment  102.  Double  ileo-colostomy  by  perforated  approximation 
plates.  The  anastomosis  between  the  lower  portion  of  the  ileum  and  the 
colon  just  above  the  cascum  was  made  without  scarification,  while  in  the  second 
operation  about  six  inches  higher  up  in  the  colon  and  ileum,  both  serous 
surfaces  were  freely  scarified.  Omentum  adherent  at  point  of  operation. 
Plates  swollen,  softened  and  pliable,  but  still  efficient  in  maintaining  coapta- 
tion and  fixation.  Adhesions  at  both  places  quite  firm,  but  more  so  in  the 
upper  portion  where  scarification  had  been  done. 

Experitrtent  103.  Ileo-colostomy  by  approximation  discs.  The  ileum  was 
divided  a  few  inches  above  the  ileo-csecal  region,  and  both  ends  closed  by 
invagination  and  three  stitches  of  the  continued  suture.  An  anastomosis  was 
made  between  the  proximal  end  and  the  ascending  colon  by  lateral  apposition. 
No  scarification.  Intestines  agglutinated  at  point  of  operation,  but  the 
adhesions  gave  way  when  the  bowel  was  forcibly  distended  under  hydrant 
pressure. 

2.     Chemical  Irritation  of  Serous  Surfaces. 

In  these  experiments  it  was  aimed  to  study  the  effect  of 
chemical  irritation  of  the  peritoneum  in  the  reparative  process  after 
intestinal  operations.  Iodine  has  been  used  for  a  long  time  in  pro- 
ducing plastic  inflammation  of  serous  surfaces  for  the  purpose  of 
obliterating  serous  cavities,  consequently  this  substance  was  used  in 
the  first  experiments.  To  study  the  effects  of  the  diffuse  application 
of  tincture  of  iron  to  the  intact  peritoneal  cavity,  the  following 
experiments  were  made: 

Experiment  104.  Medium-sized  dog.  The  needle  of  a  hypodermic  syringe 
was  thoroughly  disinfected,  and  a  drachm  of  the  tincture  of  iodine  injected 
into  the  peritoneal  cavity.  Immediately  after  the  injection  the  animal 
evinced  great  pain,  which,  however,  appeared  to  subside  after  a  short  time, 
and  subsequently  no  unfavorable  symptoms  were  observed.  Three  days  afte% 
the  injection  the  urine  was  examined  and  showed  the  presence  of  iodine. 
Dog  killed  nine  days  after  the  injection.  Circumscribed  plastic  peritonitis 
over  a  space  four  inches  square,  corresponding  to  the  point  where  the 
puncture  was  made.  At  this  place  the  omentum  was  much  thickened,  very 
vascular  and  adherent  to  the  parietal  peritoneum  and  the  adjoining  folds  of 
the  intestines. 

Experiment  105.  Medium-sized  dog.  A  fluid  drachm  of  the  tincture  of 
muriate  of  iron  was  thrown  into  the  peritoneal  cavity  by  means  of  a  well- 
disinfected  hypodermic  syringe.  The  pain  immediately  after  the  injection  was 
intense,  and  the  animal  appeared  to  be  very  ill  two  days  after  the  injection, 
and  died  with  well-marked  symptoms  of  peritonitis  on  the  sixth  day.  Diffuse 
plastic  peritonitis  was  found  to  be  the  cause  of  death.  The  omentum  was 
adherent  everywhere,  and  the  intestines  were  matted  together  by  numerous 
adhesions.  The  abdominal  cavity  contained  a  considerable  quantity  of  serous 
fluid. 


204  INTESTINAL  SURGERY. 

Remarks. — Both  experiments  prove  that  when  tincture  of  iodine 
and  tincture  of  iron  are  brought  in  contact  with  the  peritoneum,  a 
plastic  inflammation  ensues ;  and  it  was  reasonable  to  expect  that  if 
either  of  these  substances  could  be  applied  to  the  serous  surfaces 
which  it  was  intended  to  unite,  the  reparative  process  would  be 
hastened. 

Experiment  106.  Triple  ileo-ileostomy  by  perforated  decalcified  bone 
plates.  Three  internal  fi«tulse  were  made  between  the  adjacent  loops  of  the 
ileum,  about  six  inches  apart.  In  operation  No.  1,  approximation  of  intact 
serous  surfaces;  in  operation  No.  2,  the  serous  surfaces  were  painted  with 
tincture  of  iron  over  an  area  corresponding  to  the  size  of  the  plates;  in  oper- 
ation No.  3,  the  seroas  surfaces  over  the  same  extent  were  brushed  with  pure 
tincture  of  iodine.  The  animal  was  killed  forty-eight  hours  after  operation, 
and  the  following  conditions  were  noted:  No  general  peritonitis.  All  the  plates 
firmly  in  place  coaptating  the  serous  surfaces  accurately,  the  swelling  of  the 
tunics  of  the  bowel  only  serving  to  enhance  their  efficiency.  At  No.  1,  adhe- 
sions quite  firm,  flexion  of  bowel  and  marked  injection  of  serous  surfaces.  At 
No.  2,  no  adhesions  between  serous  surfaces.  The  peritoneal  surfaces  to  which 
the  tincture  of  iron  had  been  applied  appeared  stained,  almost  black,  and  at 
some  points  the  serous  coat  was  destroyed.  At  No.  3,  peritoneal  surfaces 
stained  dark  brown;  adhesions  firm,  and  an  abundance  of  plastic  lymph  even 
beyond  the  margin  of  the  plates. 

Experiment  107,  Double  ileo-ileostomy  by  approximation  plates  and 
omental  grafting.  Operation  No.  1,  approximation  of  ileum  to  ileum  by  per- 
forated decalcified  bone  plates;  serous  surfaces  intact.  Operation  No.  2, 
similar  operation  six  inches  higher  up  uniting  the  same  loops,  but  painting 
the  serous  surfaces  with  pure  tincture  of  iodine.  Operation  3,  cutting  off  a 
piece  of  omentum  two  inches  wide  and  sufiiciently  long  to  encircle  the  entire 
bowel.  After  scarifying  the  bowel  and  the  omental  graft  on  one  side,  the 
•scarified  surfaces  were  brought  in  contact,  and  the  graft  fixed  in  its  place  by 
two  fine  catgut  sutures  passed  through  the  mesentery  and  both  ends  of  the 
graft.  Animal  killed  forty-eight  hours  after  operation.  All  plates  firmly  in 
place.  At  No.  1,  adhesions  firm.  At  No.  2,  dark-brown  discoloration  of  surface 
to  which  the  iodine  had  been  applied ;  agglutination  over  the  whole  surface. 
Under  hydrostatic  pressure  the  adhesions  first  gave  way  between  the  two 
plates  where  the  iodine  had  been  applied;  showing  conclusively  that  chemical 
irritation  of  serous  surfaces  does  not  hasten  the  adhesive  process,  while  it  may, 
and  probably  does,  expedite  the  definitive  healing.  At  No.  3,  omental  graft 
firmly  adherent  to  the  entire  circumference  of  the  bowel,  and  beginning 
vascularization  of  the  graft  around  its  margins. 

Remabks. — In  all  of  these  experiments  the  post-mortem  exami- 
nations showed  no  evidences  of  diffuse  peritonitis.  In  most  of  the 
cases  the  inflammatory  process  was  limited  to  the  portion  of 
the  bowel  interposed  between  the  plates.     Without  exception  the 


OMENTAL   GRAFTING.  205 

adhesions  formed  were  firmest  and  the  definitive  healing  was 
initiated  first  where  scarification  was  performed ;  results  which  clearly 
demonstrate  the  fact  that  the  reparative  process  between  serous  sur- 
faces which  it  is  intended  to  unite,  is  hastened  by  traumatic  irritation. 
Traumatic  irritation  by  scarification  of  the  peritoneal  surface  with 
the  point  of  an  aseptic  needle,  is  the  most  potent  means  to  provoke 
a  circimiscribed  plastic  peritonitis,  and  is  followed  within  a  few 
hours  by  a  copious  exudation  of  plastic  lymph,  which,  like  a  cement 
substance,  mechanically  agglutinates  the  coaptated  serous  surfaces. 
The  same  measure,  by  destroying  the  continuity  of  the  non-vascular 
layer  of  the  peritoneum,  brings  at  once  in  contact  the  vascular  net- 
work of  both  sides  of  the  bowel,  and  opens  up  a  direct  route  for  the 
new  vessels,  an  important  element  in  the  rapid  healing  of  the  visceral 
wounds.  Chemical  irritants  by  destroying  the  endothelial  layer  of 
the  peritoneum  rather  retard,  than  favor,  early  adhesion  and  union 
between  the  coaptated  bowels,  and  should  therefore  not  be  resorted 
to  in  intestinal  surgery,  to  hasten  the  reparative  process. 

3.     Omental   Grafting. 

Under  the  head  of  circular  enterorrhaphy,  mention  is  made  of 
transplantation  of  omental  flaps  after  uniting  the  two  ends  of  the 
bowel  by  suturing  or  invagination,  with  a  view  of  securing  an  addi- 
tional safeguard  against  perforation  during  the  process  of  repair.  A 
number  of  experiments  are  described  where  the  procedure  was  prac- 
ticed with  satisfactory  results.  After  a  few  days  the  omental  flaps 
were  found  firmly  adherent  and  vascular  around  the  whole  circum- 
ference of  the  bowel,  constituting  a  ring  of  living  tissue  outside  the 
line  of  suturing.  In  all  these  cases  the  proximal  end  of  the  flap 
remained  in  connection  with  the  omentum,  and  care  was  taken  to  cut 
the  flap  in  such  a  manner  that  some  vessel  of  considerable  size  should 
furnish  the  necessary  vascular  supply.  I  was  well  aware  that  plaus- 
ible objections  could  be  entered  against  this  method,  in  that  the 
connecting  bridge  between  the  bowel  and  the  omentum  might  become 
subsequently  a  cause  of  intestinal  obstruction  by  making  traction 
upon  the  bowel,  thus  causing  a  flexion,  or,  by  becoming  a  band  of 
constriction  for  some  loop  of  intestine. 

For  the  purpose  of  obviating  such  remote  consequences  I 
resorted  to  another  procedure  which  I  have  designated  as  omental 
grafting.     I  was  familiar  with  the  fact  that  implantations  of  aseptic 


206  INTESTINAL  SURGERY. 

substances  into  the  peritoneal  cavity  had  frequently  been  done, 
without  any  immediate  or  remote  ill -effects,  and  I  had  every  reason 
to  expect  that  a  large,  completely  detached,  aseptic,  omental  graft, 
in  an  aseptic  abdominal  cavity,  would  be  well  tolerated,  and  would 
soon  become  adherent  to  the  subjacent  peritoneal  surface,  and  thus 
afford  an  additional  safeguard  against  perforation  and  the  disastrous 
consecutive  result,  namely :  perforative  peritonitis  during  the  time 
required  for  the  healing  of  the  intestinal  wound.  In  the  following 
experiments  the  grafts  used  were  from  one  and  a  half  to  two  inches 
in  width,  and  of  sufficient  length  to  completely  encircle  the  bowel. 
The  free  ends  were  made  to  project  a  few  lines  beyond  the  mesen- 
teric attachment,  and  were  fixed  by  two  fine  catgut  sutures,  each  of 
which  embraced  the  corresponding  angles  of  the  graft  and  the 
mesentery.  The  stitches  were  made  in  the  direction  of  the  mesen- 
teric vessels,  so  that  in  tying,  no  vessels  should  be  included  in  the 
suture.     In  these  experiments  dogs  were  used  exclusively. 

Experiment  108.  Three  pieces  of  omentum,  two  inches  wide  and  suffi- 
ciently long  to  encircle  the  bowel,  were  completely  detached  and  grafted  as 
follows : 

1.  Graft  simply  laid  over  the  bowel  corresponding  to  the  lower  portion 
of  the  ileum,  and  fastened  in  its  place  on  mesenteric  side  by  two  fine  catgut 
sutures. 

2.  Serous  surface  of  bowel  about  six  inches  higher  up  scarified,  and  graft 
applied  to  this  surface  and  fixed  in  the  same  manner. 

3.  Bowel  treated  in  the  same  way  about  six  inches  still  higher  up,  and 
one  of  the  serous  surfaces  of  the  graft  also  freely  scarified. 

The  graft  was  scarified  on  the  side  which  was  to  be  brought  in  contact 
with  the  bowel.  Fixation  of  graft  by  two  catgut  sutures  on  mesenteric  side. 
Animal  killed  thirty-six  hours  after  operation.  All  the  grafts  adherent, 
slightly  contracting  the  bowel  at  the  three  different  places.  On  separating 
the  adhesions  the  subjacent  serous  surface  very  vascular  and  denuded  of  its 
endothelial  layer.  Firmness  of  adhesions  increased  in  proportion  to  the 
extent  of  scarification  done,  being  least  firm  at  No.  1,  firmer  at  No.  2,  and 
firmest  at  No.  3,  where  both  coaptated  serous  surfaces  had  been  scarified.  At 
Nos.  2  and  3,  the  plastic  lymph  was  freely  supplied  with  new  blood-vessels. 
The  vascularization  was  most  conspicuous  on  the  mesenteric  side. 

Experiment  109.  Two  omental  grafts  planted  around  the  ileum  in  the 
same  manner  as  described  above.  At  No.  1,  both  the  bowel  and  the  inner  side 
of  the  graft  were  scarified;  at  No.  2,  only  the  serous  surface  of  the  bowel. 
Animal  killed  forty-three  hours  after  operation.  Stump  of  omentum  adherent 
to  abdominal  wound  and  intestines.  No  peritonitis.  At  No.  1,  graft  firmly 
adherent  over  the  entire  extent.  A  slight  extravasation  of  blood  between  the 
graft  and  the  bowel.     Beginning  vascularization  of  interposed  plastic  lymph. 


OMENTAL   GRAFTING.  207 

At  No.  2,  also  firm  adhesions  and  beginning  vascnlarization  of  the  plastic 
exudation.  Both  of  the  grafts  appear  to  be  stained  with  the  coloring  material 
of  the  blood. 

Experiment  110.  Planting  of  two  omental  grafts  around  the  ileum  about 
eight  inches  apart.  At  No.  1,  both  the  bowel  and  one  side  of  the  omental 
graft  were  scarified.  At  No.  2,  only  the  serous  surface  of  the  bowel  was  treated 
in  this  manner.  Animal  killed  six  days  after  the  operation.  Both  grafts 
firmly  adherent  throughout  and  freely  supplied  with  blood-vessels,  the  largest 
of  the  new  vessels  being  on  the  mesenteric  side.  The  omental  stump  adherent 
to  the  portion  of  bowel  between  the  grafts  where  a  flexion  had  been  made  from 
this  cause. 

Experiment  111.  In  this  experiment  omental  grafting  was  done  at  two 
points  around  the  lower  portion  of  the  ileum.  At  one  point  the  serous 
surfaces  were  left  intact,  at  the  other,  both  the  peritoneal  surface  of  the  bowel 
and  the  omental  graft  were  freely  scarified.  Animal  remained  perfectly  well 
and  was  killed  eight  days  after  operation.  No  signs  of  peritonitis.  Both 
grafts  formed  a  thin  vascular  layer  around  the  entire  circumference  of 
the  bowel,  and  firmly  and  evenly  united  throughout.  Vascularization  was 
more  marked  where  scarification  had  been  done.  On  attempting  to  separate 
the  grafts  it  was  difficult  to  find  and  define  the  line  of  union  between  the 
omentum  and  the  underlying  bowel,  as  the  union  was  very  intimate  and  firm. 

Remarks. — In  all  of  these  experiments  the  grafts  retained  their 
vitality,  and  in  a  few  hours  became  firmly  adherent  to  the  intestinal 
surface  with  which  they  had  been  brought  in  contact.  Scarification 
of  the  serous  surface  has  also  been  found  in  these  experiments,  an 
exceedingly  valuable  measure  in  hastening  the  processes  of  adhesion, 
granulation  and  vascularization.  By  planting  grafts  side  by  side, 
with  and  without  scarification,  I  was  enabled  to  determine  with 
accuracy  the  beneficial  influence  exerted  by  this  procedure  in  favor- 
ing the  reparative  process,  and  without  a  single  exception,  observed 
that  where  scarification  was  done  the  adhesions  were  firmer  and 
vascularization  more  advanced.  The  post-mortem  examinations 
appeared  to  demonstrate  that  the  firmness  of  the  adhesions  and  the 
degree  of  vascularization  were  in  direct  proportion  to  the  extent  of 
traumatic  irritation  of  the  peritoneum,  being  always  most  marked  in 
cases  where  both  the  bowel  and  the  under  surface  of  the  graft  were 
scarified,  and  least  where  intact  peritoneal  surfaces  were  brought  into 
apposition. 

As  soon  as  the  omental  grafts  were  cut  ofP  from  the  omentum 
they  were  placed  in  a  1-2000  solution  of  corrosive  sublimate,  kept 
at  the  temperature  of  the  body,  in  order  to  secure  for  the  graft  a 
perfectly  aseptic   condition  until   everything  was   in  readiness  for 


208  ^  INTESTINAL  SURGERY. 

the  transfer  of  the  graft  to  its  new  location.  Before  planting  the 
graft  it  was  carefully  dried  by  pressing  it  between  gauze  or  sponges 
wrung  out  of  the  same  solution.  The  scarifications  of  the  serous 
surfaces  should  only  be  made  sufficiently  deep  to  give  rise  to  a  very 
slight  oozing,  as  when  haemorrhage  is  more  profuse,  there  is  danger 
of  the  formation  of  a  clot  between  the  graft  and  the  bowel,  which,  if 
it  does  not  ultimately  prevent  union  between  the  coaptated  surfaces, 
must  necessarily  interfere  with  the  formation  of  early  and  firm 
adhesions. 

Omental  grafting  cannot  fail  to  become  an  established  proced- 
ure in  many  abdominal  operations.  After  suturing  a  large  wound 
of  the  stomach  or  intestines,  a  strip  of  omentum  should  be  laid 
over  the  wound  and  fastened  in  its  place  by  a  few  catgut  sutures. 
After  circular  enterorrhaphy,  the  operation  should  be  finished  by 
covering  the  circular  wound  by  an  omental  graft  about  two  inches 
wide,  which  should  be  fixed  in  its  place  by  two  catgut  sutures  passed 
through  both  ends  of  the  graft  and  the  mesentery.  Omental  graft- 
ing should  also  be  resorted  to  in  repairing  peritoneal  defects  in 
visceral  injuries  of  the  abdominal  organs,  and  in  covering  large 
stumps  after  ovariotomy  or  hysterectomy,  where  the  pedicle  is 
treated  by  the  intra-abdominal  method. 

VI.    Conclusions. 

In  conclusion  I  beg  leave  to  submit  the  following  propositions 
for  further  discussion  : 

1.  Traumatic  stenosis  from  partial  enterectomy  and  longitu- 
dinal suturing  of  the  wound  becomes  a  source  of  danger  from 
obstruction  or  perforation,  in  all  cases  where  the  lumen  of  the  bowel 
is  reduced  more  than  one-half  in  size. 

2.  Longitudinal  suturing  of  wounds  on  the  mesenteric  side  of 
the  intestine  should  never  be  practiced,  as  such  a  procedure  is 
invariably  followed  by  gangrene  and  perforation  by  intercepting  the 
vascular  supply  to  the  portion  of  bowel  which  corresponds  to 
the  mesenteric  defect. 

3.  The  immediate  cause  of  gangrene  in  circular  constriction  of 
a  loop  of  intestine  is  due  to  obstruction  of  the  venous  circulation, 
and  takes  place  first  in  the  majority  of  cases  at  a  point  most  remote 
from  the  cause  of  the  obstruction. 


CONCLUSIONS. 


209 


4.  On  the  convex  surface  of  the  bowel  a  defect  an  inch  in 
width,  from  injury  or  operation,  can  be  closed  by  transverse  suturing 
without  causing  obstruction  by  flexion.  In  such  cases  the  stenosis 
is  subsequently  corrected  by  a  compensating  bulging  or  dilatation 
of  the  mesenteric  side  of  the  bowel. 

5.  Closing  a  wound  of  such  dimensions  on  the  mesenteric  side 
of  the  bowel  by  transverse  suturing  may  give  rise  to  intestinal 
obstruction  by  flexion,  and  to  gangrene  and  perforation  by  seriously 
impairing  the  arterial  supply  to,  and  venous  return  from,  the  portion 
of  bowel  corresponding  with  the  mesenteric  defect. 

6.  Flexion  caused  by  inflammatory  and  other  extrinsic  causes 
gives  rise  to  intestinal  obstruction  only  in  case  the  functional 
capacity  of  the  flexed  portion  of  the  bowel  has  been  impaired  or 
suspended  by  the  causes  which  have  produced  the  flexion,  or  by 
subsequent  pathological  conditions  which  have  occurred  independ- 
ently of  the  flexion. 

7.  As  in  flexion,  a  volvulus  gives  rise  to  symptoms  of  obstruc- 
tion, when  the  causes  which  have  given  rise  to  a  rotation  upon  its 
axis  of  a  loop  of  bowel  have  at  the  same  time  produced  an  impair- 
ment or  suspension  of  peristalsis  in  the  portion  of  bowel  which 
constitutes  the  volvulus;  or  when  a  diminution  or  suspension  of 
peristalsis  follows  in  consequence  of  the  degree  or  extent  of  the 
rotation. 

8.  Accumulation  of  intestinal  contents  above  the  seat  of  in- 
vagination is  one  of  the  most  important  factors  which  prevents 
spontaneous  reduction,  and  which  determines  gangrene  of  the 
intussusceptum  and  perforation  of  the  bowel. 

9.  Spontaneous  disinvagination  is  not  more  frequent  in  ascend- 
ing than  descending  invagination. 

10.  The  immediate  or  direct  cause  of  gangrene  of  the  intus- 
susceptum is  obstruction  to  the  return  of  venous  blood  by  constric- 
tion at  the  neck  of  the  intussuscipiens. 

11.  Ileo-csecal  invagination,  when  recent,  can  frequently  be 
reduced  by  distention  of  the  colon  and  rectum  with  water;  but  this 
method  of  reduction  must  be  practiced  with  the  greatest  caution  and 
gentleness,  as  over-distention  of  the  colofi  and  rectum  is  productive 
of  multiple  longitudinal  lacerations  of  the  peritoneal  coat,  an  acci- 
dent which  is  followed  by  the  gravest  consequences. 

14 


210  INTESTINAL  SURGERY.      • 

12.  The  competency  of  the  ileo-csecal  valve  can  only  be  over- 
come by  over-distention  of  the  caecum,  and  is  effected  by  a  mechanical 
separation  of  the  margins  of  the  valve;  consequently  it  is  imprudent 
to  attempt  the  treatment  of  intestinal  obstruction  beyond  the  ileo- 
csecal  region  by  injections  per  rectum. 

13.  Resection  of  more  than  six  feet  of  the  small  intestine  in 
dogs  is  uniformly  fatal;  the  cause  of  death  in  such  cases  is  always 
attributable  to  the  immediate  effects  of  the  trauma. 

14.  Resection  of  more  than  four  feet  of  the  small  intestine  in 
dogs  is  incompatible  with  normal  digestion,  absorption  and  nutrition, 
and  often  results  in  death  from  marasmus. 

15.  In  cases  of  extensive  intestinal  resection,  the  remaining 
portion  of  the  intestinal  tract  undergoes  compensatory  hypertrophy, 
which  microscopically  is  apparent  by  thickening  of  the  intestinal 
coats  and  increased  vascularization. 

16.  Physiological  exclusion  of  an  extensive  portion  of  the 
intestinal  tract  does  not  impair  digestion,  absorption  and  nutrition 
as  seriously  as  the  removal  of  a  similar  portion  by  resection. 

17.  Fsecal  accumulation  does  not  take  place  in  the  excluded 
portion  of  the  intestinal  canal. 

18.  The  excluded  portion  of  the  bowel  undergoes  progressive 
atrophy. 

19.  A  modification  of  Jobert's  invagination  suture  by  lining 
the  intussusceptum  with  a  thin  flexible  rubber  ring,  and  the  substitu- 
tion of  catgut  for  silk  sutures  is  preferable  to  circular  enterorrhaphy 
by  the  Czerny-Lembert  suture. 

20.  The  line  of  suturing,  or  neck  of  intussuscipiens,  should  be 
covered  by  a  flap  or  graft  of  omentum  in  all  cases  of  circular  resec- 
tion, as  this  procedure  furnishes  an  additional  protection  against 
perforation. 

21.  In  circular  enterorrhaphy,  the  continuity  of  the  peritoneal 
surface  of  the  ends  of  the  bowel  to  be  united  should  be  procured 
where  the  mesentery  is  detached,  by  uniting  the  peritoneum  with  a 
fine  catgut  suture  before  the  bowel  is  sutured,  as  this  modification 
of  the  ordinary  method  furnishes  a  better  security  against  perfora- 
tion on  the  mesenteric  side. 

22.  In  cases  of  complete  division  of  an  intestine,  if  it  is 
deemed  advisable  not  to  resort  to  circular  enterorrhaphy,  one  or  both 


CONCLUSIONS.  *  211 

ends  of  the  bowel  should  be  closed  by  invagination  to  the  depth  of 
an  inch,  and  three  stitches  of  the  continued  suture  embracing  only 
the  peritoneal  and  muscular  coats. 

23.  The  formation  of  a  fistulous  communication  between  the 
bowel  above  and  below  the  seat  of  the  obstruction  should  take 
the  place  of  resection  and  circular  enterorrhaphy  in  all  cases  where  it 
is  impossible  or  impracticable  to  remove  the  cause  of  obstruction,  or 
where  after  excision  it  would  be  impossible  to  restore  the  continuity 
of  the  intestinal  canal  by  suturing,  or  where  the  pathological  condi- 
tions which  gave  rise  to  the  obstruction  do  not  constitute  an  intrinsic 
source  of  danger. 

24.  The  formation  of  an  artificial  anus  in  the  treatment  of 
intestinal  obstnictions  should  be  practiced  only  in .  cases  where  con- 
tinuity of  the  intestinal  canal  cannot  be  restored  by  making  an 
intestinal  anastomosis. 

25.  Gastro-enterostomy,  jejuno-ileostomy  and  ileo-ileostomy 
should  always  be  made  by  lateral  apposition  with  partially  or  com- 
pletely decalcified  perforated  bone  plates. 

26.  In  making  an  intestinal  anastomosis  for  obstruction  in  the 
csecum,  or  colon,  the  communication  above  and  below  the  seat  of 
obstruction  can  be  established  by  lateral  apposition  with  perforated 
approximation  plates,  or  by  lateral  implantation  of  the  ileum  into 
the  colon  or  rectum. 

27.  An  ileo-colostomy,  or  ileo-rectostomy  by  approximation 
with  decalcified  perforated  bone  plates,  or  by  lateral  implantation, 
should  be  done  in  all  cases  of  irreducible  ileo-csecal  invagination, 
where  the  local  signs  do  not  indicate  the  existence  of  gangrene  or 
impending  perforation. 

28.  In  all  cases  of  impending  gangrene  or  perforation,  the 
invaginated  portion  should  be  excised,  both  ends  of  the  bowel  per- 
manently closed,  and  the  continuity  of  the  intestinal  canal  restored 
by  making  an  ileo-colostomy  or  ileo-rectostomy. 

29.  The  restoration  of  the  continuity  of  the  intestinal  canal  by 
perforated  approximation  plates,  or  by  lateral  implantation,  should 
be  resorted  to  in  all  cases  where  circular  enterorrhaphy  is  impossible 
on  account  of  the  difference  in  size  of  the  lumina  of  the  two  ends  of 
the  bowel. 


I 

212  INTESTINAL  SURGERY. 

30.  In  cases  of  multiple  gunshot  wounds  of  the  intestines 
involving  the  lateral  or  convex  side  of  the  bowel,  the  formation  of 
intestinal  anastomosis  by  perforated  decalcified  bone  plates  should 
be  preferred  to  suturing,  as  this  procedure  is  equally,  if  not  more 
safe,  and  requires  less  time. 

31.  Definitive  healing  of  the  intestinal  wound  is  only  initiated 
after  the  formation  of  a  network  of  new  vessels  in  the  product  of 
tissue  proliferation  from  the  approximated  serous  surfaces. 

32.  Under  favorable  circumstances  quite  firm  adhesions  are 
found  within  the  peritoneal  surfaces  in  six  to  twelve  hours,  which 
effectually  resist  the  pressure  from  within  outward. 

33.  Scarification  of  the  peritoneum  at  the  seat  of  coaptation 
hastens  the  formation  of  adhesions  and  the  definitive  healing  of  the 
intestinal  wound. 

34.  Omental  grafts,  from  one  to  two  inches  in  width,  and 
sufficiently  long  to  completely  encircle  the  bowel,  retain  their  vitality, 
become  firmly  adherent  in  from  twelve  to  eighteen  hours,  and  are 
freely  supplied  with  blood-vessels  in  from  eighteen  to  forty-eight 
hours. 

35.  Omental  transplantation,  or  omental  grafting,  should  be 
done  in  every  circular  resection  or  suturing  of  large  wounds  of 
the  stomach  or  intestines,  as  this  procedure  favors  healing  of  the 
visceral  wound,  and  affords  an  additional  protection  against 
perforation.  .  * 


Methods  of  Intestinal  Anastomosis. 


Plate  within  the 
intestine  above 
seat  of  obstruc- 
tion. 


Perforated  de- 
calcified bone- 
plate. 


Intestinal  Anastomosis  by  Perforated  Decalcified  Bone -Plates. 


Plate  within  colon  below  seat  of 
obetruction. 


Approximation  of  intestine  by 
tying  of  sutures. 


Rubber  ring  within 
bowel  fixed  by  con- 
tinnous  catgut  sutures. 


Needles  passed  from 
within  outward  through 
entire  wall  of  bowel  and 
ring. 


Part  to  be  invagi- 
nated. 

Needles  passed 
through  serous  and 
muscular  coats. 


Author's  Modification  of  Jobert's  Suture. 

213 


KECTAL    INSUFFLATION   OF   HYDKOGEN   GAS    AN 

INFALLIBLE   TEST   IN   THE   DIAGNOSIS   OF 

YISCEEAL   INJUKY    OF    THE    GASTKO- 

INTESTINAL     CANAL     IN     PENE- 

TEATING      WOUNDS       OF 

THE     ABDOMEN. 


The  operative  treatment  of  penetrating  wounds  of  the  abdomen 
complicated  by  visceral  injury  of  the  gastro- intestinal  canal  is  now 
sanctioned  by  the  best  surgical  authorities,  and  may  be  considered 
as  a  well-established  procedure,  based  as  it  is  upon  the  results  of 
experimentation  and  clinical  experience.  A  visceral  wound  of  the 
stomach  or  any  portion  of  the  intestinal  canal  sufficient  in  size  to  give 
rise  to  extravasation  into  the  peritoneal  cavity,  must  be  looked  upon 
as  a  mortal  injury  unless  promptly  treated  by  abdominal  section.  A 
number  of  well  authenticated  cases  are  on  record  where  a  wound  in 
the  stomach  or  the  large  intestine  healed,  and  the  patients  recovered 
without  the  intervention  of  surgery,  but  these  instances  are  so  few 
that,  practically,  the  force  of  the  preceding  statement  remains  unim- 
paired. After  a  careful  study  of  an  immense  amount  of  clinical 
material  Otis  came  to  the  important  conclusion  that  gunshot  injuries 
of  the  small  intestines  under  the  old  expectant  treatment,  without 
exception  resulted  in  death;  and  that  is  a  sufficiently  cogent  argu- 
ment in  favor  of  their  treatment  by  laparotomy  as  affording  the 
only  chance  of  recovery. 

The  great  difficulty  that  presents  itself  to  the  surgeon  in  the 
absence  of  positive  symptoms,  is  the  differential  diagnosis  between  a 
simple  penetrating  wound  and  a  penetrating  wound  complicated  by 
injury  of  the  gdstro-intestinal  canal.  While  the  existence  of  serious 
intra-abdominal  haemorrhage  can  usually  be  readily  recognized  by 
well  marked  physical  signs  and  a  complexus  of  symptoms  which 
points  to  sudden  dimiuution  of  intra -arterial  pressure,  and  thus  fur- 
nishes one  of  the  positive  indications  for  treatment  by  laparotomy, 

215 


216  INTESTINAL  SURGERY. 

the  well-known  fact  remains  that  a  visceral  injury  of  the  stomach  or 
intestines  seldom  gives  rise  to  symptoms  upon  which  the  surgeon 
could  rely  in  making  a  positive  diagnosis. 

In  the  treatment  of  penetrating  wounds  of  the  abdomen  lapar- 
otomy is  resorted  to  either  (1)  for  the  purpose  of  arresting  danger- 
ous haemorrhage,  or  (2)  for  the  detection  and  treatment  of  a  wound 
or  wounds  of  its  hollow  viscera.  The  first  indication  is  readily 
recognized,  and  the  diagnosis  not  only  justifies  the  operation,  but 
imposes  it  as  a  stern  duty  upon  the  surgeon,  from  which  he  should 
never  shrink.  The  recognition  of  the  second  indication  offers 
greater  difficulties,  and  the  uncertainty  of  diagnosis  which  surrounds 
such  cases  is  used  as  a  sufficient  argument  by  many  in  opposing  the 
adoption  of  timely  and  efficient  surgical  treatment,  and  is  responsi- 
ble for  the  loss  of  many  lives  which  otherwise  might  have  been 
saved.  The  uncertainty  of  diagnosis  must  remain  in  the  way  of  a 
more  general  adoption  of  laparotomy  in  the  treatment  of  penetrating 
wounds  of  the  abdomen,  in  the  case  of  timid  surgeons,  and  the  same 
cause  may  lead  to  most  unpleasant  medico-legal  complications  in 
the  practice  of  bolder  and  more  aggressive  operators. 

Clinical  experience  and  statistics  have  demonstrated  the  impor- 
tance of  making  a  distinction  between  punctured  and  gunshot 
wounds  in  the  abdomen,  both  in  reference  to  diagnosis  and  treat- 
ment. It  is  well  known  that  penetrating  stab-wounds  are  less  likely 
to  be  complicated  by  visceral  injury  than  bullet  wounds,  conse- 
quently this  class  of  injuries  offers  a  more  favorable  prognosis  and 
does  not  call  so  uniformly  for  treatment  by  abdominal  section.  That 
penetrating  gunshot  wounds  of  the  abdomen  do  not  always  implicate 
the  gastro-intestinal  canal  has  been  well  demonstrated  by  experi- 
ment and  clinical  observation.  During  the  last  two  years  three  cases 
of  bullet  wounds  of  the  abdomen  came  under  my  observation  where 
no  doubt  could  be  entertained  that  penetration  had  taken  place,  and 
yet  all  the  patients  recovered  without  operation.  In  all  three  cases 
the  bullet  had  taken  an  antero-posterior  direction.  As  in  private 
practice  the  treatment  of  penetrating  wounds  of  the  abdomen  usually 
involves  great  medico-legal  responsibilities,  it  becomes  of  the 
greatest  importance  to  arrive  at  positive  conclusions  in  reference 
to  the  character  of  the  injury,  before  the  patient  is  svibjected  to  the 
additional  risks  to  life  incident  to  an  abdominal  section. 


RECTAL  INSUFFLATION   OF  HYDROGEN   GAS.  217 

We  will  suppose  a  case.  In  a  quarrel  a  man  is  shot  in  the 
abdomen.  The  assailant  is  placed  under  arrest.  The  surgeon  who 
is  called  establishes  the  fact  that  the  bullet  has  entered  the  abdomi- 
nal cavity,  and  from  the  point  of  entrance  and  its  probable  direction, 
he  has  reason  to  believe  that  it  has  wounded  some  part  of  the  gastro- 
intestinal canal,  and  he  concludes  to  verify  his  diagnosis  by  an 
exploratory  laparotomy;  the  operation  is  performed,  and  the  most 
careful  examination  made,  but  no  visceral  wound  is  found.  The 
wound  is  closed  and  the  patient  dies  on  the  third  or  fourth  day  of 
septic  peritonitis.  The  attorney  for  the  state  charges  the  defendant 
with  murder. 

The  defense  will  very  naturally  raise  the  questions:  "Did  the 
man  die  of  the  injury,  or  the  operation?"  "Shall  the  defendant  be 
tried  for  assault  and  battery,  or  for  murder?"  During  the  trial  the 
attending  surgeon  is  made  the  target  for  a  volley  of  a  medley  of 
scientific  and  unscientific  questions  by  the  cunning  attorney  for  the 
defense  in  his  attempt  to  save  his  client  from  the  gallows  or  state 
prison  for  life,  at  the  expense  of  the  reputation  of  the  surgeon  and 
the  respect  and  good  name  of  the  art  and  science  of  surgery.  This 
picture  is  not  overdrawn.  Such  cases  have  happened  and  will 
happen  again.  It  is  apparent  that  if  some  infallible  diagnostic  test 
could  be  applied  in  cases  of  penetrating  wounds  of  the  abdomen 
which  would  indicate  to  the  surgeon  the  presence  or  absence  of 
visceral  lesions  of  the  gastro-intestinal  canal,  the  indication  for 
aggressive  treatment  would  become  clear  and  the  medico-legal 
responsibility  of  the  operator  would  be  reduced  to  a  minimum. 

As  we  can  never  expect  by  a  study  of  symptoms  or  by  the  ordi- 
nary physical  examination  to  fill  this  gap,  I  was  induced  to  search 
for  some  reliable  test  which  in  such  cases  should  prove  that  the 
penetrating  bullet  or  instrument  had  injured  the  gastro-intestinal 
canal.  It  occurred  to  me  that  a  wound  in  the  stomach  or  intestine 
should  be  sought  for  in  some  such  way  as  the  plumber  locates  a 
leak  in  a  gas-pipe.  The  first  object  to  be  accomplished  was  to  prove 
the  permeability  of  the  entire  gastro-intestinal  canal  to  inflation  of 
air,  and  the  next  step  was  to  find  some  innocuous  gas  which,  when 
inflated,  would  escape  from  the  intestinal  wound  into  the  peritoneal 
cavity,  and  from  there  through  the  external  wound,  where  its  pres- 
ence could  be  proved  by  some  infallible  test. 


218  INTESTINAL  SURGERY. 

I.    Permeability  of  the  Ileo-Caecal  Talye  to  Rectal  Insuffla- 
tion of  Air  or  Gas. 

A  great  deal  has  been  said  and  written  in  reference  to  the  per- 
meability of  the  ileo-csecal  valve  to  injections  of  fluids  into  the  rectum, 
or  to  the  insufflation  of  air  or  gases.  The  majority  of  those  who 
have  studied  this  subject  clinically  or  by  experiment  rtiako  the  posi- 
tive assertion  that  the  ileo-csecal  valve  is  perfectly  competent,  and 
effectually  guards  the  ileum  against  the  entrance  of  both  fluids  and 
gases  forced  into  the  rectum,  while  others  insist  that  it  is  permeable 
only  in  exceptional  cases,  and  only  a  few  claim  that  its  resistance  can 
be  overcome  by  a  moderate  degree  of  pressure.  HeschP  made  a 
number  of  experiments  and  satisfied  himself  that  the  ileo-csecal 
valve  serves  as  a  safe  and  perfect  barrier  against  the  entrance  of 
fluids  from  below.  In  testing  the  resisting  power  of  the  coats  of 
the  intestine  he  found  that  the  serous  coat  of  the  colon  gave  way 
first  to  overdistention,  while  the  remaining  tunics  yielded  subse- 
quently to  a  somewhat  slighter  pressure.  The  small  intestine  of  a 
child  on  being  subjected  to  overdistention  ruptured  first  on  the 
mesenteric  side,  the  place  where  acquired  diverticida  are  found. 

BulP  has  found  that  in  the  adult  one  litre  of  water  injected  by 
the  rectum  will  reach  the  csecum,  but  that  the  entire  capacity  of 
the  large  intestine  is  from  four  to  five  litres.  He  is  of  the  opinion 
that  in  the  living  body,  fluid  cannot  be  forced  beyond  the  ileo-csecal 
valve,  although  ancient  and  modern  experimenters  claim  to  have 
succeeded  in  the  cadaver.  He  affirms  that  when  the  rectum  is  dis- 
tended by  air,  the  ileo-csecal  valve  is  rendered  incompetent  and  the 
air  passes  into  the  small  intestines. 

Cantani^  is  a  firm  believer  in  the  permeability  of  the  ileo-csecal 
valve  to  fluid  rectal  injections.  In  one  instance  he  treated  a  case  of 
coprostasis  by  an  injection  of  a  litre  and  a  half  of  oil  per  rectimi, 
and  an  hour  later  a  part  of  the  oil  was  ejected  by  vomiting.  He 
advises  that  the  intestinal  tract  above  the  ileo-csecal  valve  should  be 
utilized  as  an  absorbing  surface  in  cases  requiring  rectal  alimenta- 

^  Zur  Mechanik  diastaltischen  Darmperforationen.   Wiener  Med.  Wochen- 
schrift,  No.  1,  1881. 

2  Virchow's  Jahresbericht,  B.  11,  1878,  S.  205. 

3  Virchow's  Jahresbericht,  B.  11,  1879,  S.  180. 


PERMEABILITY  OF  ILEO-C^CAL    VALVE.  219 

tion,  and  that  when  in  a  diseased  condition  it  should  be  treated  by- 
topical  applications. 

Behrens^  concluded  from  his  experiments  that  it  required  the 
insufflation  per  rectum  of  one  and  one-eighth  litres  of  air  to  reach 
the  ileum  through  the  ileo-csecal  valve.  In  his  experiments  he  had 
no  difficulty  in  overcoming  the  competency  of  the  ileo-csecal  valve 
by  rectal  insufflation  of  air. 

Debierre'^  made  numerous  experiments  on  the  cadaver  to  test 
the  permeability  of  the  ileo-caecal  valve  to  rectal  injections  of  fluids 
or  inflation  of  air.  The  results  which  he  obtained  wore  not  constant. 
In  some  subjects  the  valve  proved  only  permeable  to  air,  in  others, 
to  both  air  and  water,  while  iu  some  no  air  or  fluids  could  be  forced 
into  the  ileum  by  any  degree  of  force.  When  the  intestine  was  left 
in  situ  the  valve  was  found  less  permeable  than  when  the  intestine 
had  been  removed  from  the  body.  He  attributed  the  different 
degrees  of  competency  of  the  valve  to  variations  in  the  anatomical 
construction  of  the  valve.  If  both  lips  of  the  valve  were  equal  in 
length,  or  if  the  lower  lip  was  longer  the  valve  was  found  imper- 
meable. It  proved  permeable  in  cases  where  the  lower  lip  was 
shorter,  contracted,  and  smaller  than  the  upper.  In  the  last  instance, 
the  advancing  volume  of  fluid  or  air  lifted  the  upper  valve,  while 
in  the  former  structure  of  the  valve,  the  margins  of  the  lips  of  the 
valve  were  pressed  against  each  other,  perfectly  shutting  off  all  com- 
munication between  the  colon  and  the  ileum. 

Mr.  Lucas ^  enumerates  the  following  objections  against  forcible 
rectal  injections  of  water  as  a  means  of  reducing  invagination: 

1.  Owing  to  its  weight  it  exerts  much  too  strong  lateral 
pressure  for  the  intestine  safely  to  bear,  and  he  has  found  it  easy  to 
rupture  the  bowel  after  death  by  forcing  in  water. 

2.  Should  reduction  have  been  accomplished,  the  contact  of 
a  large  quantity  of  water  with  the  large  bowel  is  apt  to  increase 
the  tendency  to  diarrhoea.  He  claims  very  properly,  that  air,  on  the 
other  hand,  is  a  natural  occupant  of  the  intestinal  canal,  and  whilst 

^  Ueber   den  Werth  der   Kiinstlichen   Auftreibung    des   Dickdarmes   mit 
Gasen  u.  Flussigkeiten.     Gottingen.     Dissertation.     1886. 

2  La  valvule  de  Bauhin  consideree  comme  barriers  des  apothicaires.   Lyon 
Medicale,  No.  45,  1885. 

3  On  Inversion  with  Inflation  in  the  Cure  of  Intussusception.    The  Lan- 
cet, January  16,  1886. 


220  INTESTINAL  SURGERY. 

its  pressure  is  of  the  gentlest  its  presence  excites  no  unnatural 
peristaltic  action.  He  administers  an  anaesthetic  to  the  point  of 
relaxation  before  the  inflation  is  attempted. 

Dawson^  made  a  number  of  experiments  on  the  cadaver  and 
came  to  the  conclusion  that  when  the  ileo-csecal  valve  is  in  a  normal 
condition  it  effectually  guards  the  small  intestine  against  the  ingress 
of  fluids  from  below.  Illoway^  has  devised  a  force-pump  which  he 
strongly  recommends  for  the  purpose  of  forcing  water  beyond  the 
ileo-csecal  valve,  in  case  the  seat  of  an  intestinal  obstruction  is  located 
above  that  point.  He  reports  four  cases  of  intestinal  obstruction 
treated  by  this  method,  three  of  which  recovered.  Battey^  asserts  the 
permeability  of  the  entire  alimentary  canal  by  enema,  and  verifies 
his  statement  by  the  recital  of  his  own  clinical  experience  and 
experiments  upon  the  cadaver. 

Ziemssen  recommends  inflation  of  the  rectum  for  diagnostic 
and  therapeutic  purposes  and  proceeds  as  follows:  A  rectal  tube 
about  six  inches  long  is  carried  into  the  anus  and  fixed  by  pressing 
together  the  nates,  the  patient  lying  on  the  back.  A  funnel  is  then 
connected  with  the  rectal  tube  by  means  of  rubber  tubing.  For 
complete  inflation  of  the  large  intestine  three  drams  of  bicarbonate 
of  soda  and  four  and  a  half  drams  of  tartaric  acid  are  separately  dis- 
solved in  water  and  portions  of  either  solution  alternately  added. 
To  prevent  sudden  overdistention  of  the  bowel  it  is  advised  to  add 
the  solutions  at  intervals  of  several  minutes.  A  very  important  use 
of  this  method  is  to  diagnosticate  the  position  of  contractions,  stric- 
tures, or  occlusion  of  the  intestine  in  cases  in  which  it  is  desirable 
to  operate,  and  also  to  show  the  position  of  peritoneal  adhesions. 
The  result  of  his  observations  has  led  him  to  believe  that,  as  a  rule, 
the  small  intestine  is  completely  closed  to  the  entrance  of  substances 
from  the  colon,  by  the  ileo-csecal  valve.  Under  the  influence  of 
deep  chloroform  narcosis,  however,  this  resistance  is  lessened,  and 
fluids  can  be  thrown  into  the  small  intestine. 

Since  this  work  has  gone  to  press  my  attention  has  been  called 
by  Dr.  Eastman,  of  Indianapolis,  to  a  paper  on  "  Fifty  Laparotomies," 
etc.,  which  he  published  in  Progress,  for  January,  1888,  in  which 

1  Lancet  and  Clinic,  Feb.  21,  1885. 

2  American  Journal  Medical  Sciences,  Vol.  41,  p.  168. 

^  Transactions  of  the  American  Medical  Association,  1878. 


PERMEABILITY   OF  ILEO-C^CAL    VALVE.  221 

he  describes  a  case  of  pelvic  abscess  where  he  resorted  to  Bergeon's 
method  of  rectal  insuffiation  of  sulphuretted  hydrogen  gas  after 
the  abscess  was  opened,  to  determine  whether  it  communicated  with 
the  large  intestine.  In  the  same  paper  appears  a  case  of  resection 
of  the  colon  where  the  same  test  was  used  after  suturing,  to  prove 
the  efficiency  of  the  sutures. 

In  my  paper  read  at  the  last  International  Medical  Congress' 
the  following  experiments  appear,  which  illustrate  the  difficulty  in 
overcoming  the  resistance  of  the  ileo-caecal  valve  by  rectal  injections 
of  water: 

Experiment  23.  While  completely  tinder  the  influence  of  ether,  an  incision 
was  made  through  the  linea  alba  of  a  cat,  sufficiently  long  to  render  the  ileo- 
caecal  region  readily  accessible  to  light.  An  incision  was  made  into  the  ileum 
just  above  the  valve  and  by  gently  retracting  the  margins  of  the  wound,  the 
valve  could  be  distinctly  seen.  Water  was  then  injected  into  the  rectum,  and 
as  the  C£ecum  became  well  distended  it  could  be  readily  seen  that  the  valve 
became  tense  and  appeared  like  a  circular  curtain,  preventing  effectually  the 
escape  even  of  a  drop  of  fluid  into  the  Ueum.  The  competency  of  the  valve 
was  only  overcome  by  overdistention  of  the  caecum,  which  mechanically  sepa- 
rated its  margins,  allowing  a  fine  stream  of  water  to  escape  into  the  ileum. 
The  insufficiency  of  the  valve  was  clearly  caused  by  great  distention  of  the 
caecum.  That  such  a  degree  of  distention  is  attended  by  no  inconsiderable 
danger,  was  proved  by  this  experiment,  as  the  cat  was  immediately  killed,  and 
on  examination  of  the  colon  and  rectum,  a  number  of  longitudinal  rents  of 
the  peritoneal  coat  was  found. 

Experiment  24.  In  this  experiment  a  cat  was  fully  narcotized  with  ether 
and  while  the  body  was  inverted,  water  was  injected  per  rectum  in  sufficient 
quantity  and  adequate  force,  by  means  of  an  elastic  syringe,  to  ascertain  the 
force  required  to  overcome  the  resistance  offered  by  the  ileo-caecal  valve. 
Great  distention  of  the  caecum  could  be  clearly  mapped  out  by  percussion  and 
palpation  before  any  fluid  passed  into  the  ileum.  As  soon  as  the  obstruction 
at  the  valve  was  overcome,  the  water  rushed  through  the  small  intestines,  and 
having  traversed  the  entire  alimentary  canal,  issued  from  the  mouth.  About 
a  quart  of  water  was  forced  through  in  this  manner.  The  animal  was  killed 
and  the  gastro-intestinal  canal  carefully  examined  for  injuries.  Two  longi- 
tudinal lacerations  of  the  peritoneal  surface  of  the  rectum,  over  an  inch  in 
length,  were  found  on  opposite  sides  of  the  bowel. 

Experiment  25.  This  experiment  was  conducted  in  the  same  manner  as 
the  foregoing,  only  that  the  cat  was  not  etherized.  More  than  a  quart  of 
water  was  forced  through  the  entire  alimentary  canal  from  anus  to  mouth. 
The  animal  lived  for  eight  days,  but  suffered  during  the  whole  time  with 

1  An  Experimental  Contribution  to  Intestinal  Surgery  with  Special 
Beference  to  the  Treatment  of  Intestinal  Obstruction. 


222  INTESTINAL  SURGERY. 

symptoms  of  ileo-colitis.  A  post-mortem  examination  was  not  made,  althongh 
the  symptoms  manifested  during  life  leave  no  doubt  that  they  resulted  from 
injuries  inflicted  by  the  injection. 

It  will  thus  be  seen  that  in  the  three  cases  where  fluid  was 
forced  beyond  the  ileo-csecal  valve,  in  two  of  them  the  post-mortem 
revealed  raiiltiple  lacerations  of  the  peritoneal  coat  of  the  large 
intestines,  while  the  third  animal  sickened  immediately  after  the 
experiment  was  made,  and  died  eight  days  later  from  the  effects 
of  the  injuries  inflicted.  These  experiments  combined  with  clinical 
experience  leave  no  further  doubt  that,  practically,  the  ileo-csecal 
valve  is  not  permeable  to  fluids  from  below,  and  that  for  diagnostic 
and  therapeutic  uses  it  is  unsafe  and  unjustifiable  to  attempt  to 
force  fluids  beyond  the  ileo-csecal  valve.  We  should  a  priori  expect 
that  air  and  gases,  on  account  of  their  less  weight  and  greater 
elasticity  than  water,  could  be  forced  along  the  intestinal  canal  with 
less  force,  and  for  that  reason  alone,  if  for  no  other,  should  be  pre- 
ferred to  water  in  cases  where  it  appears  desirable  to  distend  the 
intestine  above  the  ileo-csecal  valve.  The  results  obtained  by  experi- 
mental research  in  the  past  speak  in  favor  of  rectal  inflation  by  air 
or  gas  in  all  cases  where  for  diagnostic  or  therapeutic  purposes  it 
becomes  necessary  to  dilate  the  entire  or  a  portion  of  the  gastro- 
intestinal canal. 

I.    Rectal  Insufflation  of  Air. 

Experiment  J.'  Dog,  weight  seventy-iive  pounds.  The  animal  was  pro- 
foundly anaesthetized,  and  by  means  of  an  ordinary  elastic  syringe,  air  was 
forced  through  the  rectum  until  the  whole  abdomen  became  distended  and 
tympanitic.  The  abdominal  cavity  was  opened  in  the  median  line,  and  the 
whole  intestinal  canal  was  found  distended.  An  incision  about  an  inch  in 
length  was  made  about  the  middle  of  the  small  intestines,  when  air  escaped, 
and  about  one  foot  of  the  intestine  on  either  side  of  the  wound  collapsed. 
The  remaining  portion  of  the  intestines  remained  unafifected  by  the  incision. 
The  animal  was  killed,  and  every  part  of  the  entire  gastro-intestinal  canal 
carefully  examined  for  injuries.  The  ileo-caecal  valve  remained  intact,  and 
no  evidence  of  rupture  of  any  of  the  coats  of  the  intestines  could  be  detected. 

Experiment  2.  Dog,  weight  twelve  pounds.  Under  full  anaesthesia  the 
gastro-intestinal  canal  was  inflated  in  the  same  manner  as  in  the  preceding 
experiment,  and  the  inflation  was  carried  to  the  same  extent.    On  opening  the 

^  These  experiments  were  made  at  the  County  Hospital,  and  my  thanks 
are  due  to  Dr.  M.  E.  Connel,  superintendent  of  the  hospital,  and  his  assistants, 
and  Dr.  Wm.  Mackie  of  Milwaukee,  for  valuable  assistance. 


RECTAL   INSUFFLATION   OF  AIR.  223 

abdomen  in  the  median  line  the  distended  loops  of  the  intestines  protruded 
from  the  wound,  and  partial  exventration  was  allowed  to  take  place  for  the 
purpose  of  examining  the  intestine  for  injuries.  The  closest  inspection  failed 
to  detect  evidences  of  partial  or  complete  rupture  of  any  of  the  tunics.  One 
of  the  distended  coils  of  intestine  was  incised  at  opposite  points  on  the  lateral 
aspect,  the  incisions  being  an  inch  in  length.  Only  a  limited  segment  of  the 
bowel  on  each  side  of  the  wounds  collapsed,  and  although  the  peristalsis  was 
active,  more  remote  portions  were  emptied  very  slowly.  The  wounds  were 
united  transversely  for  the  purpose  of  making  an  artificial  diverticulum.  The 
animal  recovered  without  any  untoward  symptoms. 

Experiment  3.  Dog,  weight  thirteen  pounds.  Animal  profoundly  etherized, 
and  air  inflated  as  in  former  experiments.  The  distended  colon  could  be 
clearly  mapped  out  by  percussion  before  a  gurgling  sound  in  the  region  of  the 
ileo-caecal  valve  indicated  that  the  air  had  entered  the  ileum.  After  this  had 
occurred  the  middle  of  the  abdomen  became  prominent  and  tympanitic.  As 
soon  as  the  resistance  offered  by  the  ileo-caecal  valve  had  been  overcome, 
it  required  less  force  to  distend  the  remaining  portion  of  the  gastro-intestinal 
canal.  The  inflation  was  carried  to  the  extent  of  distending  the  stomach,  an 
event  which  was  easily  recognized  by  a  considerable  prominence  in  the 
epigastric  region  which  was  tympanitic  on  percussion.  At  this  time  an 
elastic  tube  was  inserted  into  the  stomach,  and  its  free  end  immersed  under 
water.  Bubbles  of  air  escaped  freely,  and  the  abdominal  distention  was 
materially  diminished.  As  the  inflation  was  continued  the  air  would  escape 
through  the  stomach-tube,  showing  that  a  moving  current  of  air  existed 
between  the  rectal  tube  and  the  stomach  tube.  The  abdominal  distention 
which  remained  after  the  experiment  had  completely  disappeared  after 
eighteen  hours,  and  the  animal  never  manifested  pain  or  any  other  symptoms 
of  disease. 

Experiment  4.  Dog,  weight  fifteen  pounds.  In  this  experiment  inflation 
was  practiced  without  anaesthesia.  The  rigidity  of  the  abdominal  muscles 
greatly  interfered  with  the  distention  of  the  colon  to  a  requisite  degree 
to  overcome  the  competency  of  the  ileo-caecal  valve.  The  passage  of  air  from 
the  caecum  into  the  ileum  through  the  ileo-caecal  valve  was  announced  by  an 
audible  gurgling  sound  which  was  repeated  at  intervals,  as  the  caecum,  after 
partial  collapse,  was  again  distended  by  renewing  the  inflation.  The  insuffla- 
tion was  continued  until  the  stomach  became  distended  by  air,  which  caused 
vomiting  and  copious  eructations  of  air.  The  dog  remained  in  perfect  health 
after  the  inflation. 

These  experiments  prove  the  feasibility  of  forcing  air  through 
the  entire  alimentary  canal  from  below  upwards.  In  not  a  single 
experiment  could  any  structural  changes  be  found  in  the  walls  of  the 
intestine,  and  all  animals  not  killed  immediately  after  the  experiment 
recovered.  The  results  of  these  experiments  contrast  strongly  with 
those  by  rectal  injections  with  water  where  the  same  objects  were  in 


224  INTESTINAL  SURGERY. 

view.  In  the  latter  experiments  the  force  requisite  to  overcome  the 
ileo-caecal  valve  invariably  produced  lacerations  of  the  peritoneal 
coat  of  the  bowel,  which  in  themselves  would  constitute  a  grave 
source  of  danger. 

It  now  became  necessary  for  me  to  prove  that  the  ileo-csecal 
region  in  man  in  so  far  resembled  that  of  the  dog,  that  the  ileo- 
caecal  valve  could  be  rendered  more  readily  incompetent  by  inflation 
of  air  than  by  injections  of  fluids.  The  following  two  experiments 
were  made  for  this  purpose: 

Experiment  5.  A  young  man,  twenty-five  years  of  age,  a  patient  in  the 
Milwaukee  Hospital,  under  treatment  for  a  tumor  in  the  epigastric  region,  was 
subjected  to  the  experiment.  He  was  placed  flat  on  the  back.  On  percussion 
the  whole  umbilical  region  was  found  flat  and  the  abdominal  wall  retracted. 
No  anaesthesia.  With  an  ordinary  elastic  syringe  air  was  injected  slowly  into 
the  rectum.  As  inflation  progressed  the  outlines  of  the  entire  colon  could  be 
clearly  seen  and  accurately  mapped  out  by  percussion.  The  ctecal  region 
especially  became  very  prominent.  The  inflation  was  continued  very  slowly, 
and  as  soon  as  the  air  passed  through  the  ileo-csecal  valve,  the  hypogastric  and 
umbilical  regions  began  to  rise  and  resonance  replaced  the  former  dullness  on 
percussion.  The  arrival  of  air  in  the  stomach  was  indicated  by  distention  of 
the  epigastric  region,  disappearance  of  the  contour  of  the  tumor  and  resonance 
on  percussion.  During  the  whole  process  of  inflation  the  patient  only  com- 
plained of  a  slight  pain  in  the  splenic  flexure  of  the  colon,  and  a  sensation  of 
fullness  in  the  abdomen.  As  soon  as  it  became  apparent  that  the  stomach 
was  distended  by  air,  a  stomach-tube  was  introduced  and  its  free  end  placed 
under  water.  As  the  inflation  was  continued,  bubbles  of  air  continued  to  escape. 
On  assuming  the  erect  position  the  patient  complained  of  colicky  pains  in  the 
umbilical  region,  which  were  undoubtedly  caused  by  an  exaggerated  peristalsis. 
The  pain,  however,  soon  disappeared,  and  on  the  following  day  he  was  as  well 
as  usual. 

Experiment  6.  Adult  male,  suffering  from  neurasthenia.  Experiment  and 
result  the  same  as  in  No.  5,  only  that  in  this  case  the  pain  due  to  distention  of 
the  colon  was  referred  to  the  ileo-caecal  region,  and  the  colicky  pain  in  the 
umbilical  region  persisted  for  a  longer  time.  The  air  was  again  forced  from 
anus  to  mouth  without  causing  any  injury  whatever  and  only  moderate  degree 
of  pain  for  a  short  time. 

The  foregoing  experiments  demonstrate  conclusively  that  in  the 
human  subject  by  a  moderate  degree  of  force,  short  of  producing 
any  injury  of  the  tunics  of  the  intestines,  air  can  be  forced  along  the 
entire  alimentary  tract,  and  that  this  procedure  can  be  resorted  to 
with  perfect  safety  for  diagnostic  and  therapeutic  purposes  in  all 
cases  where  the  tissues  of  the  intestinal  wall  have  not  sufPered  too 
much  loss  of  resistance  from  antecedent  pathological  changes. 


INFLATION  OF  GAS  THROUGH  STOMACH.  225 

2.   Inflation  of  Alimentary  Canal  through  Stomach  Tube. 

We  should  naturally  expect  that  the  alimentary  canal  could  be 
inflated  with  more  ease  and  with  a  less  degree  of  force  by  following 
the  normal  peristaltic  wave.  That  this  is  not  the  case  will  be  seen 
from  the  following  experiments : 

Experiment  7.  Dog,  weight  forty  pounds  (18  kilograms).  After  com- 
plete aneesthesia  was  effected  a  flexible  rubber  tube  was  introduced  into  the 
stomach,  and  the  free  end  of  the  tube  connected  with  a  four-gallon  rubber 
balloon  containing  hydrogen  gas,  by  means  of  a  rubber  tube.  Between  the 
gas  reservoir  and  the  stomach-tube  a  manometer  was  interposed,  registering 
accurately  the  force  used  in  making  the  inflation.  The  inflation  was  made  by 
compressing  the  rubber  bag.  A  tube  was  introduced  into  the  rectum  to  facili- 
tate the  escape  of  gas  that  might  reach  this  portion  of  the  intestinal  tract. 
Under  a  pressure  of  one  pound  and  a  half  the  stomach  dilated  rapidly,  and 
later  the  entire  abdomen  became  distended  and  resonant  on  percussion,  but 
no  gas  escaped  per  rectum.  When  the  pressure  was  increased  to  two  pounds 
(.9  kilogram),  no  further  distention  of  the  abdomen  took  place,  as  the  gas 
escaped  along  the  side  of  the  stomach  tube.  At  this  time  respiration  became 
greatly  embarrassed,  but  was  relieved  on  allowing  gas  to  escape  through  the 
stomach-tube.  On  compressing  the  abdomen  firmly  the  distention  disappeared 
almost  completely;  at  the  same  time  a  large  quantity  of  gas  continued  to 
escape  through  the  stomach-tube.  Inflation  was  renewed,  and  under  a  pressure 
of  one  pound  and  a  half,  the  abdomen  again  became  uniformly  distended. 
When  the  pressure  was  increased  to  two  pounds  (.9  kilogram)  the  dog  sud- 
denly died,  and  all  efforts  at  resuscitation  failed.  On  opening  the  abdomen 
the  stomach  was  found  enormously  distended,  reaching  three  inches  below  the 
umbilicus,  occupying  almost  the  entire  abdominal  cavity.  The  upper  half  of 
the  small  intestines  was  distended;  numerous  points  of  sharp  flexions  were 
found  among  the  different  distended  coils.  The  distended  stomach  had 
evidently  encroached  so  much  upon  the  abdominal  space  as  to  render  the 
greater  part  of  the  intestinal  canal  impermeable  by  pressure. 

Experiment  8.  Dog,  weight  fifteen  pounds.  After  the  animal  was  placed 
fully  under  the  influence  of  ether,  the  abdomen  was  opened  and  the  csecum 
and  lower  portion  of  ileum  drawn  forward  into  the  wound,  and  a  large  aspi- 
rator needle  inserted  into  the  ileum  just  above  the  ileo-caecal  valve.  Through 
a  rubber  tube  hydrogen  gas  was  forced  into  the  stomach.  Under  one  pound 
(.45  kilogram)  of  pressure,  the  stomach  and  upper  portion  of  the  intestines 
dilated  readily.  When  the  force  was  increased,  the  gas  returned  through  the 
oesophagus  along  the  sides  of  the  stomach-tube. 

Experiment  9.  Dog,  medium  size.  This  animal  was  killed  to  ascertain 
the  results  of  an  experiment  made  for  another  purpose.  Rubber  balloon  con- 
taining hydrogen  gas,  and  manometer  were  used  for  making  the  inflation. 
The  tube  through  which  the  inflation  was  made  was  tied  in  the  oesophagus. 
The  abdomen  was  distended  enormously,  and  on  increasing  the  pressure  to 

15 


226  INTESTINAL  SURGERY. 

three  and  three-fourths  pounds  (1.7  kilograms),  still  no  gas  escaped  through 
the  rectal  tube.  The  abdomen  was  then  opened,  when  the  stomach  was  found 
so  enormously  distended  that  it  fiUed  almost  the  entire  abdominal  cavity. 
About  one-fourth  of  the  length  of  the  small  intestines  was  found  distended, 
and  among  the  distended  loops  numerous  acute  flexions  could  be  seen.  After 
the  abdomen  was  opened,  under  long  and  continuous  distention,  the  peritoneal 
covering  of  the  stomach  gave  way,  when  the  manometer  registered  only  one 
pound  and  a  half  of  pressure. 

Experiment  10.  Dog,  weight  eighteen  pounds  (8  kilograms).  Immedi- 
ately after  death  the  oesophagus  was  isolated  and  the  tube  of  the  hydrogen 
gas  Inflator  securely  tied  in,  and  a  glass  tube  was  inserted  into  the  rectum. 
Under  a  pressure  of  two  and  three-fourths  pounds  (1.2  kilograms),  registered 
by  the  manometer,  the  gas  first  dilated  the  stomach  and  then  passed  along  the 
intestines  until  it  escaped  in  a  steady  stream  through  the  rectal  tube,  where  it 
was  ignited.  On  opening  the  abdomen  the  stomach  was  found  greatly  dis- 
tended, while  the  distention  of  the  intestines  was  a  great  deal  less  marked. 
None  of  the  tunics  of  the  stomach  or  intestines  were  injured. 

Experiment  11.  Dog,  weight  twenty  pounds  (9  kilograms).  Animal 
etherized  and  a  flexible  tube  connected  with  the  gas  inflator  introduced  into 
the  stomach,  and  a  glass  tube  into  the  rectum.  On  inflation  the  stomach 
became  gradually  distended,  and  when  the  pressure  had  reached  one  pound 
and  a  half  (.7  kilogram),  the  dog  vomited  and  a  good  deal  of  gas  escaped  at 
the  same  time.  Inflation  was  again  commenced  and  was  followed  by  uniform 
distention  and  tympanites  over  the  entire  abdomen;  when  the  pressure 
reached  two  pounds  and  a  half  (1.1  kilograms),  the  gas  escaped  from  the 
rectum,  and  when  ignited  burned  with  a  steady  blue  flame.  The  experiment 
was  followed  by  no  unfavorable  symptoms. 

Experiment  12.  Dog,  weight  twelve  pounds  (5.4  kilograms).  Under  the 
influence  of  ether  inflation  with  hydrogen  gas  in  the  same  manner  as  in  last 
experiment.  As  soon  as  the  stomach  became  well  distended,  and  the  manom- 
eter registered  one  pound  and  a  half  of  pressure,  vomiting  occurred,  attended 
by  a  free  escape  of  gas,  which  was  followed  by  collapse  of  the  distended 
epigastric  region.  When  inflation  was  resumed,  it  was  noted  that  any  increase 
of  pressure  over  one  pound  (.45  kilogram)  was  followed  by  regurgitation  of 
gas,  and  on  this  account  it  was  found  impossible  to  inflate  the  lower  portion 
of  the  intestinal  tract.    No  unfavorable  symptoms  followed  the  experiment. 

Experiment  13.  Dog,  weight  twenty-eight  pounds  (12.7  kilograms).  Under 
the  influence  of  ether  inflation  of  hydrogen  gas  through  the  stomach  tube. 
As  soon  as  the  pressure  was  increased  to  more  than  one  pound  (.45  kilo- 
gram) the  gas  escaped  along  the  sides  of  the  tube  through  the  oesophagus; 
consequently  only  the  upper  portion  of  the  abdomen  could  be  distended,  and 
the  inflation  evidently  did  not  extend  much  beyond  the  stomach.  The  experi- 
ment was  repeated  several  times  with  the  same  result.  The  animal  remained 
perfectly  well  after  the  experiment. 

Experiment  14.  Dog,  weight  twelve  pounds  (5.4  kilograms).  •  Inflation  of 
stomach  by  hydrogen  gas  under  full  anaesthesia.     The  effect  of   the  infla- 


PRESSURE   EXPERIMENTS.  227 

tion  was  the  same  as  in  the  last  experiment;  only  the  stomach  and  npper 
portion  of  the  small  intestines  could  be  distended  and  further  inflation  was 
impossible,  as  the  gas  escaped  from  the  stomach  as  soon  as  the  pressure 
exceeded  one  pound  (.45  kilogram).  A  large  aspirator  needle  was  pushed 
through  the  linea  alba  into  the  stomach,  and  the  gas  which  escaped  through  it, 
on  being  lighted,  burned  with  the  characteristic  blue  flame.  After  the  needle 
was  withdrawn,  the  inflation  was  continued  to  ascertain  if  the  puncture  in  the 
stomr^ch  would  allow  the  escape  of  gas  into  the  peritoneal  cavity.  The  infla- 
tion was  continued  until  the  entire  abdomen  was  distended  by  the  gas.  That 
the  distention  and  tympanites  was  due  to  the  presence  of  gas  in  the  peritoneal 
cavity  became  evident,  as  it  remained  after  the  stomach  had  been  emptied  of 
its  gas,  and  on  percussion  it  was  ascertained  that  the  entire  liver  dullness  had 
disappeared.  The  dog  recovered  without  symptoms  of  peritonitis  or  any 
other  ill-effects  from  the  experiment. 

These  experiments  demonstrate  conclusively  that  it  is  more 
difficult  to  inflate  the  alimentary  canal  from  above  downwards  than 
from  below  upwards,  as  in  the  living  animal  I  succeeded  only  in  one 
instance  in  forcing  hydrogen  gas  from  mouth  to  anus,  while  in  others 
a  degree  of  force  sufficient  to  rupture  the  peritoneal  coat  of  the 
stomach,  only  effected  distention  of  the  stomach  and  upper  portion 
of  intestinal  canal.  It  is  evident  that  great  distention  of  the 
stomach  constitutes  an  important  factor  in  causing  or  aggravating 
intestinal  obstruction,  as  it  effects  compression  which  causes 
impermeability  of  the  intestines,  or  aggravates  conditions  arising 
from  an  antecedent  partial  permeability,  by  producing  sharp  flexions 
among  the  distended  coils  of  the  intestines.  For  diagnostic  and 
surgical  purposes  the  stomach  can  be  readily  inflated  almost  to  any 
extent  through  a  stomach  tube,  and  when  it  becomes  necessary  to 
ascertain  the  presence  of  a  visceral  wound  or  perforation  of  this 
organ,  this  method  of  inflation  may  be  resorted  to  with  advantage. 

3.    Experiments  to  Determine  the  Degree  of  Force  which 

is  Necessary  to  Overcome  the  Resistance  Offered 

by  the  Ileo-Caecal  Valve. 

Accurate  experiments  to  determine  the  force  required  to  render 
the  ileo-csecal  valve  incompetent  by  insufflation  of  air  or  gas  having 
not  heretofore  been  made,  as  it  is  exceedingly  important  to  obtain 
some  accurate  information  on  this  subject,  the  following  experiments 
were  made.  In  all  experiments  air  or  hydrogen  gas  was  used.  The 
inflation  was  made  with  a  rubber  balloon.      The  pressure  was  esti- 


228  INTESTINAL  SURGERY. 

mated  either  with  a  mercury  gauge  or  with  a  manometer,  as  used  by 
gas-fitters  and  plumbers.  The  manometer  or  mercury  gauge  was 
connected  by  means  of  rubber  tubing  with  the  rectal  tube  on  one 
side  and  the  rubber  balloon  on  the  other.  The  rubber  balloon  in 
which  the  hydrogen  gas  was  collected  held  four  gallons,  and  numer- 
ous experiments  showed  that  when  the  gas  was  forced  through  the 
opening  of  a  stopcock,  the  lumen  of  which  was  about  the  size  of  a 
knitting  needle,  a  compression  equal  to  two  hundred  pounds  (91 
kilograms)  would  never  register  more  than  three  pounds  (1.4  kilo- 
grams) of  pressure.  In  the  living  subject  the  escape  of  air  or  gas 
from  the  rectum  was  prevented  by  an  assistant  pressing  the  margins 
of  the  anus  firmly  against  the  rectal  tube. 

Experiment  15.  Dog,  weight  thirty -five  pounds  (16  kilograms).  Imme- 
diately after  death  the  lower  portion  of  the  rectum  was  isolated  and  the 
rectal  tube  inserted  and  fixed  in  its  place  by  tying  a  string  firmly  around 
the  rectum.  The  abdomen  was  opened  and  the  intestines  left  in  situ.  The 
ileum  was  cut  transversely  six  inches  above  the  ileo-ctecal  valve  and  a  glass 
tube  inserted  into  the  distal  end,  which  was  also  tied  in.  Hydrogen  gas  was 
inflated  from  a  rubber  balloon.  Under  a  pressure  of  three-quarters  of  a 
pound  (.3  kilogram)  the  caecum  was  dilated,  and  a  moment  later  the  gas 
escaped  from  the  glass  tube  and  was  ignited;  the  flame  remained  steady 
under  a  pressure  of  from  one-half  to  three-quarters  of  a  pound  (.2  to  .3 
kilogram). 

Experiment  16.  Dog,  weight  twenty  pounds  (9  kilograms).  Same  as  in 
the  preceding  experiment,  only  that  the  resistance  of  the  ileo-csecal  valve  was 
overcome  under  a  pressure  of  one-half  pound  (.2  kilogram).  The  distention 
of  colon  and  caecum  was  moderate,  and  signs  of  injury  to  the  tunics  could  not 
be  found  in  either  experiment. 

Experiment  17.  Dog,  weight  twenty-three  pounds  (10  kilograms).  In 
this  experiment  the  abdomen  was  opened  immediately  after  death,  and  a  large 
hypodermic  needle  inserted  into  the  ileum  a  short  distance  above  the  ileo- 
caecal  valve  before  the  inflation  of  hydrogen  gas  was  made.  A  pressure  of 
three-quarters  of  a  pound  (.3  kilogram)  was  sufficient  to  force  the  gas  through 
the  ileo-caecal  valve  and  through  the  needle;  the  valve  remained  open  under  a 
steady  pressure  of  one-half  pound  (.2  kilogram). 

Having  determined  that  air  and  gas  could  be  forced  beyond  the 
ileo-caecal  valve  in  dogs  under  very  low  pressure,  varying  from  one- 
half  to  three-quarters  of  a  pound,  I  proceeded  to  test  the  degree  of 
resistance  of  the  ileo-caecal  valve  in  the  human  subject. 

Experiment  18.  Strong,  healthy  young  man.  The  subject  was  placed  flat 
upon  his  back  and  hydrogen  gas  was  inflated  from  a  rubber  balloon.  At  first 
the  gas  was  forced  in  very  slowly  under  a  pressure  of  one  pound  and  a  half 


PRESSURE  EXPERIMENTS.  229 

(.7  kilogram),  which  distended  the  colon  visibly  as  far  as  the  csecnm.  As 
the  distention  appeared  to  remain  the  same,  the  pressure  was  increased  to  two 
pounds  (.9  kilogram),  when  suddenly  the  indicator  of  the  manometer  receded 
to  one  pound  (.45  kilogram),  and  the  umbilical  region  became  prominent 
and  resonant,  showing  conclusively  that  the  ileo-csecal  valve  had  been  passed 
and  the  small  intestines  were  filling  rapidly  with  gas.  As  soon  as  the  whole 
abdomen  had  become  distended  and  tympanitic,  the  manometer  again  regis- 
tered one  pound  and  a  half  (.7  kilogram)  of  pressure,  and  remained  at  this 
figure  for  some  time  after  further  inflation  was  discontinued  by  turning  the 
stopcock. 

Experiment  19.  Young  man,  in  good  health.  Experiment  conducted  in 
the  same  manner  as  before.  After  the  colon  and  caecum  had  been  well  dilated 
the  manometer  registered  two  and  one-quarter  pounds  (1  kilogram),  and  the 
umbilical  region  became  prominent  and  resonant.  As  the  inflation  advanced 
the  average  pressure  was  one  pound  and  three-quarters  (.8  kilogram),  and 
twice  it  was  increased  to  two  and  a  half  pounds  (1.1  kilograms),  when  the 
patient  complained  of  pain  in  the  umbilical  region.  As  soon  as  the  stopcock 
was  turned  the  pressure  sank  to  three-quarters  of  a  pound  (.3  kilogram). 

These  two  experiments  prove  that  in  a  normal  condition  the 
ileo-csecal  valve  in  a  healthy  adult  person  is  overcome  by  rectal 
inflation  under  a  pressure  of  one  and  a  half  to  two  and  a  quarter 
pounds  (.7  to  1.1  kilograms).  This  amount  of  pressure  is  not 
sufficient  to  injure  the  ttmics  of  a  healthy  intestine,  and  in  both 
instances  the  subjects  of  the  experiments  complained  but  little  of 
the  immediate  or  remote  effects  of  the  experiments.  As  the  result 
of  numerous  observations,  I  can  state  that  when  the  inflation  is  made 
slowly  and  continuously  there  is  less  danger  of  injuring  the  intes- 
tines than  when  the  inflation  is  made  rapidly,  or  with  interruptions. 
Slow  and  gradual  distention  of  the  caecum  is  best  adapted  to 
overcome  the  competency  of  the  ileo-csecal  valve,  by  effecting  dias- 
tasis of  the  margins  of  the  valve.  A  rubber  balloon  holding  from 
two  to  four  gallons  (10  to  20  litres)  recommends  itself  as  the  most 
efficient  and  safest  instrument  for  making  rectal  insufflation  for 
therapeutic  or  diagnostic  purposes. 

The  following  experiments  were  made  to  determine: 

4.    The  Amount  of  Pressure  Necessary  to  Force  Hydrogen 

Gas  Through  the  Entire  Alimentary  Canal 

by  Rectal  Inflation. 

Experiment  20.  Dog,  weight  thirty-five  pounds  (16  kilograms).  Immedi- 
ately after  death  rectal  inflation  of  hydrogen  gas  was  made,  and  a  pressure  of 
one  pound  (.45  kilogram)  sufl&ced  to  distend  the  entire  abdominal  cavity,  and 


230  INTESTINAL  SURGERY. 

when  a  tube  was  introduced  into  the  stomach  and  a  burning  taper  applied  to 
its  end,  a  blue  flame  at  once  appeared  and  continued  as  long  as  the  inflation 
was  kept  up  under  the  same  pressure. 

Experiment  21.  Dog,  weight  twelve  pounds  (5.4  kilograms).  Under  ether 
narcosis  rectal  inflation  of  hydrogen  gas  from  rubber  balloon.  The  ileo-csecal 
valve  ofifered  very  little  resistance,  and  as  soon  as  the  manometer  registered 
one  pound  and  a  half  (.7  kilogram)  of  pressure  the  gas  escaped  through  the 
stomach  tube  which  had  been  introduced  previously,  and  on  applying  a  lighted 
taper  it  burned  with  a  continuous  flame  as  long  as  the  inflation  was  continued. 

Experiment  22.  Dog,  weight  twenty  pounds  (9  kilograms).  Experiment 
and  result  same  as  in  last;  the  pressure  never  exceeded  one  pound  and  a  half 
(.7  kilogram). 

Exjjeriment  23.  Dog,  weight  nineteen  pounds  (8.6  kilograms).  In  this 
experiment  no  anaesthetic  was  used,  and  in  consequence  the  pressure  had  to  be 
increased  to  three  pounds  (1.4  kilograms)  before  the  gas  escaped  through  the 
stomach  tube.  On  account  of  the  violent  contractions  of  the  abdominal  muscles 
the  escape  of  gas  was  intermittent,  the  flame  being  frequently  extinguished 
by  an  absence  of  the  gas. 

Experiment  24.  Dog,  weight  twenty-one  pounds  (9.5  kilograms).  The 
animal  being  completely  under  the  influence  of  ether  the  abdomen  was  opened 
in  the  median  line,  and  the  ileo-csecal  region  made  accessible  to  sight.  Hydro- 
gen gas  was  inflated  per  rectum,  and  under  a  pressure  of  three-quarters  of  a 
pound  (.3  kilogram)  readily  passed  the  ileo-caecal  valve,  and  under  one  pound 
of  pressure  it  ascended  the  intestinal  canal,  and  in  a  few  seconds  reached  the 
stomach.  A  tube  was  introduced  into  the  stomach,  and  as  the  gas  escaped  it 
was  ignited  and  burned  with  a  steady  flame. 

Experiment  25.  Dog,  weight  eighteen  pounds  (8  kilograms).  Rectal 
insufflation  of  hydrogen  gas,  the  dog  being  fully  under  the  influence  of  an 
anaesthetic.  The  colon  and  caecum  were  only  slightly  distended  when  the  gas, 
under  one-quarter  of  a  pound  (.1  kilogram)  of  pressure,  passed  the  ileo-cascal 
valve.  Under  one  pound  (.45  kilogram)  of  pressure,  the  abdomen  became  uni- 
formly distended  and  tympanitic,  and  when  a  tube  was  introduced  into  the 
stomach  the  escaping  gas  was  ignited  and  burned  with  a  steady  flame  as  long 
as  the  pressure  was  continued. 

Experiment  26.  Dog,  weight  twenty  pounds  (9  kilograms).  Animal  ether- 
ized, and  when  completely  relaxed  hydrogen  gas  was  inflated  per  rectum,  and 
passed  the  ileo-csecal  valve  under  a  pressure  of  half  a  pound  (.2  kilogram).  The 
stomach  became  distended  under  a  pressure  of  one  pound  and  a  half  (.7  kilo- 
gram), and  on  the  introduction  of  a  tube  the  escaping  gas  was  ignited  and 
burned  with  a  continuous  flame  as  long  as  the  manometer  registered  half  a 
pound  (.2  kilogram)  of  pressure. 

In  all  animals  where  the  insufflation  was  not  complicated  by 
abdominal  section,  no  unpleasant  symptoms  followed  the  experiments. 
All  of  the  animals  recovered  as  rapidly  as  after  an  ordinary  ether  nar- 
cosis.    In  all  of  the  experiments  the  pressure  fell  rapidly  after  the 


RESISTANCE   OF  STOMACH  TO  DIASTALTIC  FORCE.         231 

ileo-csecal  valve  had  been  opened,  but  the  pressure  had  again  to  be 
increased  before  the  gas  reached  the  stomach.  It  usually  required 
one-half  to  one  pound  more  pressure  to  force  gas  through  the  entire 
alimentary  canal  than  when  it  was  forced  only  through  the  ileo-csecal 
valve.  Whenever  it  becomes  desirable  to  conduct  the  hydrogen  gas 
a  considerable  distance  along  the  intestines,  or  through  the  entire 
alimentary  canal,  it  is  exceedingly  important  to  proceed  slowly  with 
the  inflation,  as  under  slow  distention  half  a  pound  (.2  kilogram)  of 
pressure  will  accomplish  in  time  a  greater  degree  of  distention  than 
four  times  this  amount  of  pressure  if  the  force  is  applied  quickly, 
and  only  for  a  short  time,  and  is  attended  by  much  less  risk  of 
injury  to  the  coats  of  the  intestines.  I  am  quite  convinced  that  in 
the  dog,  rectal  insufflation  of  hydrogen  gas  made  under  a  pressure  of 
one-quarter  of  a  pound,  if  made  very  slowly,  the  abdominal  walls 
being  completely  relaxed  by  an  anaesthetic,  will  not  only  overcome 
the  resistance  ofPered  by  the  ileo-csecal  valve,  but  will  prove  sufficient 
to  force  the  gas  through  the  whole  length  of  the  alimentary  canal. 

I  have  already  sufficiently  demonstrated  the  permeability  of  the 
ileo-csecal  valve  and  the  entire  alimentary  canal  in  animals  and  man 
to  rectal  insufflation  of  air  and  gas,  and  I  shall  now  endeavor  to 
establish  the  safety  of  this  procedure  as  a  diagnostic  and  therapeutic 
measure  by  showing: 

II.    The  Resistance  of  Different  Portions  of  the  Gastro- 
intestinal Canal  to  Diastaltic  Force. 

I.    Stomach. 

Experiment  27.  Large,  healthy,  adult  dog.  Experiment  made  immedi- 
ately after  death.  Stomach  in  situ.  CEsophagus  tied  and  distention  made 
with  a  force  pump  from  pyloric  orifice,  the  organ  being  rapidly  dilated  with 
air.  When  the  manometer  registered  eight  and  one-half  pounds  (3.9  kilo- 
grams) of  pressure,  the  stomach  was  distended  at  least  eight  times  its  normal 
size,  when  a  rent  in  the  peritoneal  covering  an  inch  and  a  half  in  length 
parallel  to,  and  near  the  omental  attachment,  occurred. 

Experiment  28.  Middle-aged  man,  died  of  sepsis.  The  whole  gastro-in- 
testinal  canal  showed  marked  evidences  of  septic  gastro-entero-colitis,  the 
mucous  membrane  being  softened,  very  vascular,  and  dotted  with  numerous 
hsemorrhagic  infarcts.  Organ  in  situ  inflated  with  air  in  the  same  manner  as 
in  last  experiment.  Longitudinal  rupture  of  peritoneal  coat  along  anterior 
surface  under  two  and  one-half  pounds  of  pressure  (1.1  kilograms),  and  when 
it  was  increased  to  three  pounds  (1.4  kilograms),  the  whole  thickness  of  the 
wall  at  the  lesser  curvature  ruptured. 


232  INTESTINAL  SURGERY. 

2.    Small  Intestines. 

Experiment  29.  Subject  same  as  in  experiment  28.  Lower  portion  of 
ileum  under  five  pounds  (2.3  kilograms)  of  pressure,  became  emphysematous 
along  mesenteric  attachment,  and  ruptured  completely  as  soon  as  the  mano- 
meter registered  five  and  three-fourths  pounds  (2.6  kilograms)  of  pressure. 

Experiment  30.  Dog,  weight  twenty  pounds  (S  kilograms).  Immediately 
after  death  the  lower  part  of  the  ileum,  with  mesenteric  attachment  intact, 
was  gradually  distended  and  remained  intact  until  a  pressure  of  ten  pounds 
(4.5  kilograms)  was  reached,  when  air  escaped  between  the  two  serous  layers 
of  the  mesentery,  showing  that  minute  ruptures  at  numerous  points  had  taken 
place.  When  the  distention  had  reached  its  maximum,  the  segment  of  bowel 
inflated  was  elongated  twice  its  normal  length. 

Experiment  31.  Upper  portion  of  ileum  of  same  animal  when  distended 
to  its  utmost  gave  way  under  a  pressure  of  eight  pounds  (S.ti  kilograms),  the 
peritoneal  coat  on  convex  side  rupturing  to  the  extent  of  two  inches  (51  mm.) 
parallel  to  the  axis  of  the  bowel. 

Experiment  32.  The  middle  portion  of  the  small  intestines,  when  sub- 
jected to  a  pressure  of  eight  pounds  (3.6  kilograms),  sustained  a  longitudinal 
rupture  of  the  peritoneum  on  convex  surface,  and  the  remaining  tunics  gave 
way  when  the  pressure  was  increased  to  nine  pounds  (4.1  kilograms). 

t 

3.     Colon. 

Experiment  33.  Subject  same  as  experiments  28  and  29.  Experiment  was 
made  twenty-four  hours  after  death.  Colon  and  caecum  apparently  very  much 
softened  and  mucous  membrane  in  a  state  of  inflammation.  One  foot  (30  cm.) 
of  the  transverse  colon  isolated  and  gradually  distended,  when  the  peri- 
tqpeal  coat  along  the  border  of  one  of  the  longitudinal  bands  ruptured  under 
a  pressure  of  two  pounds  and  a  half  (1.1  kilograms).  The  peritoneal  lacera- 
tion became  very  extensive  before  the  remaining  tunics  ruptured  under  a 
pressure  of  four  pounds  (1.8  kilograms). 

Experiment  34.  Dog,  weight  eighteen  pounds  (8.2  kilograms).  Imme- 
diately after  death  the  ileum  was  tied  just  above  the  caecum,  and  the  inflation 
made  per  rectum.  Air  was  pumped  in  gradually  with  a  force-pump  and  when 
the  pressure  reached  ten  pounds  and  a  half  (4.8  kilograms),  air  escaped 
between  the  peritoneal  layers  of  the  meso -colon;  at  this  stage  the  longitudinal 
distention  of  the  bowel  exceeded  twice  its  normal  length. 

Experiment  35.  Dog,  weight  twenty-three  pounds  (10.4  kilograms). 
Experiment  the  same  as  the  preceding.  Air  was  pumped  in  rapidly  until  the 
mercury  gauge  registered  ten  and  a  half  pounds  (4.8  kilograms)  of  pressure, 
when  the  sigmoid  flexure  on  its  free  surface  gave  way  with  a  loud  report,  the 
rent  being  about  one  inch  and  a  half  (38  mm.)  in  length. 

Experiment  36.  Dog,  weight  eighteen  pounds  (8.2  kilograms).  Entire 
colon  distended  by  rectal  inflation  of  air,  the  ileum  being  tied  just  above  the 
ileo-c£ecal  valve.  Under  a  pressure  of  six  pounds  (2.7  kilograms),  the  peri- 
toneum ruptured  in  a  longitudinal  direction,  oj^posite  the  meso-colon,  and 
the  remaining  tunics  gave  way  a  little  later,  under  the  same  pressure. 


DISTENTION   OF  GASTRO-INTESTINAL   CANAL.  233 

These  experiments  are  of  the  greatest  importance  in  showing 
that  the  pressure  which  was  found  necessary  to  apply  in  rupturing 
a  healthy  intestine,  was  greatly  in  excess  of  that  which  is  required 
to  force  air  through  the  ileo-csecal  valve,  or  even  the  whole  length 
of  the  alimentary  canal.  It  only  requires  from  one-quarter  of  a 
pound  to  a  pound  and  a  half  (.1  to  .7  kilogram)  of  pressure  to  force 
air  through  the  ileo-caecal  valve,  and  from  half  a  pound  to  two 
pounds  and  a  half  (.2  to  1.1  kilograms)  to  force  it  from  anus  to 
mouth,  while  even  the  weakest  portion  of  the  gastro- intestinal  canal 
eflPectually  resisted  a  distending  force  of  from  eight  to  ten  pounds 
(3.6  to  4.5  kilograms). 

The  experiments  on  the  human  cadaver,  where  the  resisting 
power  of  the  gastro-intestinal  canal  to  diastaltic  force  was  greatly 
reduced  by  ante-mortem  pathological  changes,  show  that  under  such 
circumstances  it  would  have  been  safe  to  resort  to  inflation,  as  the 
pressure  required  to  rupture  the  colon  or  small  intestines  exceeded 
that  which  has  been  found  adequate  to  force  air  or  gas  beyond  the 
ileo-csecal  valve,  or  even  the  entire  length  of  the  alimentary  canal. 
When  an  intestine  is  slowly  distended  to  its  utmost  capacity  by 
inflation  of  air  or  gas,  and  the  pressure  is  maintained  uninterruptedly, 
rupture  occurs  at  one  of  two  points ;  either  a  longitudinal  laceration 
of  the  peritoneal  coat  takes  place  on  the  convex  surface  of  the  bowel 
opposite  the  mesenteric  attachment,  or  minute  ruptures  on  the 
mesenteric  side  give  rise  to  extravasation  of  air  or  gas  between  the 
two  serous  layers  of  the  mesentery.  In  either  case,  if  the  pressure 
is  increased,  complete  rupture  takes  place  at  the  point  where  the 
laceration  first  commenced. 

III.     Distention    of    Gastro-Intestinal    Canal    by    Rectal 
Insufflation  of  Hydrogen  Gas. 

In  this  section  will  be  found  an  account  of  the  experiments 
which  were  made  preliminary  to  the  practical  application  of  the 
hydrogen  gas  test  as  a  diagnostic  measure  in  penetrating  wounds 
of  the  abdomen,  and  which  furnish  only  so  many  more  demonstra- 
tions of  the  permeability  of  the  ileo-csecal  valve  and  the  entire 
alimentary  canal  to  rectal  inflation  of  hydrogen  gas. 

Experiment  37.  Dog,  weight  fifteen  pounds  (6.8  kilograms).  Under  ether 
anaesthesia,  hydrogen  gas  from  rubber  balloon  was  slowly  forced  into  the 
rectum  until  the  entire  anterior  abdominal  wall  had  become  uniformly  dis- 


234  INTESTINAL  SURGERY. 

tended  and  tympanitic,  -when  the  distended  stomach  was  punctured  with  a 
large  aspirator  nee'dle  and  gas  escaped  in  a  steady  stream,  which  when  ignited 
burned  with  a  continuous  flame.  After  a  considerable  portion  of  the  gas  had 
been  evacuated  in  this  manner  the  upper  abdominal  region  receded,  and  the 
flame  was  extinguished.  The  animal  recovered  without  any  untoward 
symptoms. 

Experiment  38.  Dog,  weight  seventeen  pounds  (7.7  kilograms).  Without 
ansesthesia  hydrogen  gas  was  inflated  per  rectum  until  it  escaped  through  a 
tube  which  had  been  introduced  into  the  stomach.  As  it  escaped  from  the 
stomach  tube  it  was  ignited  and  burned  with  a  large  blue  flame.  The  abdom- 
inal muscles  were  so  rigid  that  distention  was  never  well  marked,  and  the 
inflation  required  a  good  deal  more  force  than  in  animals  where  muscular 
rigidity  had  been  overcome  by  an  anaesthetic.  The  dog  remained  perfectly 
well  after  the  experiment,  and  in  a  few  hours  the  remaining  tympanites  had 
disappeared. 

Experiment  39.  Dog,  weight  thirty-five  pounds  (15.8  kilograms).  No 
anaesthetic  used.  On  account  of  rigidity  of  abdominal  muscles  it  required 
persistent  efforts  to  force  hydrogen  gas  from  rubber  balloon  per  rectum 
through  the  whole  alimentary  canal.  As  soon  as  the  stomach  had  become 
distended  by  the  gas,  the  animal  vomited;  at  the  same  time  gas  escaped 
by  repeated  eructations.  The  animal  manifested  no  signs  of  suffering  after 
the  experiment. 

Experiment  40.  Dog,  weight  twenty-seven  pounds  (12.2  kilograms). 
Under  anaesthesia  hydrogen  gas  was  inflated  per  rectum  until  it  escaped 
through  tube  which  had  been  introduced  into  the  stomach;  a  lighted  taper 
was  applied  to  the  free  end  of  the  tube,  and  the  gas  ignited  and  burned  with 
the  characteristic  blue  flame. 

Experiment  41.  Large  Newfoundland  dog.  Under  anaesthesia  a  duoden- 
ostomy  was  made,  and  hydrogen  gas  injected  per  rectum  and  ignited  as  it 
escaped  from  a  rubber  tube,  which  had  been  inserted  into  the  distal  portion 
of  the  bowel  through  the  fistula. 

Experiment  42.  Adult  male;  abdominal  organs  healthy;  no  anaesthesia. 
Inflation  of  hydrogen  gas  per  rectum.  The  gas  was  stored  in  a  four-gallon 
(9  litres)  rubber  balloon  and  was  forced  into  the  rectum  by  compression.  As 
the  distention  progressed  the  colon  could  be  distinctly  mapped  out  from 
sigmoid  flexure  to  caecum  by  inspection  and  percussion.  As  soon  as  the 
CEecum  had  become  visibly  prominent,  a  stethoscope  was  applied  over  the  ileo- 
cecal region,  and  as  the  valve  became  incompetent  by  overdistention  of 
caecum,  a  distinct  gurgling  sound  could  be  heard  as  the  gas  entered  the  ileum. 
Whenever  inflation  was  arrested  the  gurgling  sound  disappeared,  but  was 
heard  again  whenever  the  ileo-caecal  valve  was  opened  by  renewed  inflation. 

Distention  of  the  small  intestines  was  attended  by  resonance 
and  prominence  of  umbilical  and  hypogastric  regions.  The  incom- 
petency of  the  ileo-csecal  valve  was  invariably  announced  by  a 
reduction  in  the  pressure.     The  patient  complained  of  a  sensation 


DISTENTION  OF  GASTRO-INTESTINAL   CANAL.  235 

of  distention  in  the  umbilical  region  and  intermittent  colicky  pains 
which,  however,  disappeared  completely  after  a  few  hours.  The 
pain  appeared  to  be  less  severe  than  after  similar  experiments  with 
inflation  of  air. 

Experiment  43.  Young  man  in  comparatively  good  health.  Inflation 
same  as  in  preceding  experiment.  Auscultation  over  ileo-caecal  valve  revealed 
the  same  sounds  as  the  gas  escaped  from  the  colon  into  the  ileuru.  The  sound 
seemed  to  vary  somewhat  according  to  the  size  of  the  opening  in  the  valve 
and  the  force  used  in  making  the  inflation,  and  always  disappeared  as  the 
valve  closed  after  suspension  of  inflation.  The  colicky  pains  subsided  as 
the  small  intestines  emptied  themselves  of  their  new  contents.  The  assistant 
who  compressed  the  rubber  balloon  was  always  able  to  announce  the  beginning 
of  the  incompetency  of  the  ileo-csecal  .valve,  by  experiencing  a  sudden 
diminution  in  the  pressure. 

Experiment  44.  Adult  male,  suffering  from  gastric  catarrh.  Hydrogen 
gas  inflation  per  rectum  to  extent  of  causing  great  distention  of  abdomen, 
which  caused  the  hepatic  dullness  to  ascend  at  least  two  inches.  Auscultatory 
signs  the  same.  Sharp  colicky  pains  in  the  umbilical  region  were  relieved  by 
a  free  escape  of  gas  through  rectum. 

Experiment  45.  Hysterical  female.  Abdomen  flat  and  dull  on  percussion 
from  umbilicus  to  pubes;  no  resonance  over  sigmoid  flexure.  Rectal  inflation 
with  hydrogen  gas.  Compression  of  rubber  balloon  corresponding  to  only 
one-fourth  pound  (.1  kilogram)  of  pressure  readily  dilated  the  whole  colon,  its 
course  being  indicated  by  a  distinct  prominence  and  tympanitic  resonance 
from  sigmoid  flexure  to  csecum.  Under  the  same  pressure  the  gas  escaped 
with  little  or  no  resistance  through  the  ileo-caecal  valve  from  the  colon  into 
the  ileum,  the  occurrence  being  attended  by  the  characteristic  auscultatory 
sounds  and  followed  by  distention  and  resonance  of  space  from  umbilicus  to 
pubes.  Amount  of  gas  inflated  about  four  litres.  The  patient  complained  of 
some  pain  in  the  region  of  the  splenic  flexure  of  the  colon  during  the  disten- 
tion of  the  colon,  and  later  of  slight  intermittent  pain  in  the  region  of  the 
umbilicus. 

Experiment  46.  Middle-aged  woman,  suffering  from  retroversion  of  the 
uterus.  Abdomen  flaccid  and  dull  on  percussion  in  the  median  line  from 
umbilicus  to  pubes.  Rectum  distended  with  hardened  faeces.  Hydrogen  gas 
inflated  in  the  usual  manner.  The  mercury  gauge  registered  two  and  a  half 
pounds  (1.1  kilograms)  of  pressure  before  the  gas  reached  the  sigmoid  flexure, 
after  this  it  fell  to  one  pound  (.45  kilogram),  and  the  inflation  progressed 
without  any  further  resistance.  As  soon  as  the  gas  passed  through  the  ileo- 
csecal  valve  the  pressure  fell  to  three-quarters  of  a  pound  (.3  kilogram),  and 
remained  so  during  the  inflation  of  the  small  intestines,  slight  variations 
marking  the  opening  and  closing  of  the  ileo-caecal  valve.  As  the  umbilical 
and  hypogastric  regions  became  prominent  and  tympanitic  the  patient  com- 
plained of  a  griping  pain.  About  eight  litres  of  gas  were  injected.  A  few 
hours  after  the  experiment  all  symptoms  had  disappeared. 


236  INTESTINAL  SURGERY. 

Experiment  il.  Female  recently  operated  on  for  laceration  of  perineum. 
Rectum  empty.  Abdomen  flaccid ;  umbilical,  hypogastric,  and  right  iliac 
regions  dull  on  percussion.  The  inflation  was  made  very  slowly  and  the 
pressure  never  exceeded  one  pound  (.45  kilogram).  As  the  large  intestine 
became  distended  the  transverse  colon  came  plainly  into  view.  On  ausculta- 
tion over  the  ileo-csecal  valve  the  escape  of  gas  into  the  ileum  was  marked  by 
a  blowing  sound,  which  was  increased  or  diminished  in  pitch  by  the  degree  of 
pressure.  As  the  lower  portion  of  the  small  intestines  became  distended  the 
lower  part  of  the  abdomen  became  prominent  and  tympanitic,  and  the  patient 
complained  of  colicky  pains.  About  three  litres  of  gas  were  inflated.  In  half 
an  hour  the  patient  appeared  as  well  as  before  inflation. 

Experiment  48.  Middle-aged  physician  suffering  from  typhlitis.  This 
was  the  second  attack,  and  the  acute  symptoms  had  subsided.  Over  the  caecum 
a  circumscribed  area  of  dullness  and  tenderness.  On  palpation  it  appeared 
as  though  the  swelling  were  adherent  to  the  anterior  abdominal  wall.  The 
area  of  dullness  was  outlined  externally  by  pencil  marks,  before  inflation  was 
commenced.  As  the  colon  became  distended  under  a  pressure  of  one-fourth 
of  a  pound  (.1  kilogram),  the  circumscribed,  indurated  region  became  more 
prominent,  imparting  to  the  palpating  fingers  the  feeling  of  hardness,  but  on 
percussion  it  was  resonant,  showing  conclusively  that  the  inflamed  and  indu- 
rated wall  of  the  caBcum  had  been  lifted  forward  by  the  pressure  of  the  gas. 
Under  the  same  pressure  the  gas  escaped  in  a  continuous  stream  into  the 
ileum,  its  passage  through  the  ileo-caecal  valve  being  attended  by  a  well- 
marked  blowing,  gurgling  sound.  The  patient  felt  the  entrance  of  gas  into 
the  ileum  distinctly,  and  complained  soon  after  of  a  slight  colicky  pain  in  the 
umbilical  region.  The  space  between  umbilicus  and  pubes,  which  before  infla- 
tion was  completely  dull  on  percussion,  now  became  more  prominent  and 
tympanitic.     Only  two  litres  of  gas  were  used  in  this  experiment. 

Experiment  49.  Young  physician  in  perfect  health.  Region  between 
umbilicus  and  pubes  perfectly  duU  on  percussion,  also  left  iliac  fossa.  Infla- 
tion of  four  litres  of  hydrogen  gas  under  one-third  of  a  pound  (.15  kilogram) 
pressure.  The  outlines  of  the  distended  colon  could  be  clearly  seen  and 
marked  out  by  percussion  before  the  gas  escaped  into  the  small  intestines. 
The  passage  of  gas  through  the  ileo-csecal  valve  was  again  attended  by  a  well- 
marked  gurgling  sound,  after  which  the  entire  abdomen  became  prominent 
and  tympanitic.  The  patient  felt  a  sensation  of  distention  during  the  infla- 
tion of  the  colon,  and  as  the  small  intestines  became  distended,  complained 
of  griping  pains.  Gas  escaped  freely  by  eructations  and  per  rectum,  which 
soon  relieved  the  colicky  pains  in  the  umbilical  region. 

Experiment  50.  Medical  student  in  robust  health.  Region  from  umbilicus 
to  pubes  flat  on  percussion,  while  the  course  of  the  entire  colon  was  tympan- 
itic. Rectal  inflation  with  hydrogen  gas.  When  the  resistance  of  the  ileo- 
caecal  valve  was  overcome  the  mercury  gauge  registered  one-half  pound  (.2 
kilogram)  of  pressure.  The  passage  of  gas  through  the  ileo-csecal  valve  was 
attended  by  a  gurgling  sound  which  was  heard  at  some  distance  by  a  number 
of  persons  present  in  the  room.    Later  a  continuous  blowing  (almost  amphoric) 


DISTENTION   OF  GASTRO-INTESTINAL   CANAL.  237 

sound  could  be  heard  over  the  ileo-csecal  valve.  The  subject  of  the  experi- 
ment was  conscious  of  the  passage  of  gas  from  colon  into  ileum,  and  soon 
after  complained  of  a  colicky  pain  which  he  referred  to  the  umbilical  region. 
The  whole  abdomen  became  uniformly  distended  and  tympanitic  on  percus- 
sion, and  the  distress  caused  by  the  great  distention  was  only  relieved  by  a 
free  escape  of  gas  by  eructations  and  through  the  rectuna.  Four  litres  of  gas 
were  used  in  this  experiment. 

Experiment  51.  Young  physician  in  good  health.  Rectal  inflation  of  four 
litres  of  hydrogen  gas  under  a  pressure  of  only  one-third  j)Ound  (.15  kilogram). 
Distention  of  colon  well-marked  previous  to  escape  of  gas  through  the  ileo- 
csecal  valve.  As  soon  as  the  gas  entered  the  ileum  the  middle  and  lower 
portion  of  the  abdomen  became  distended  and  tympanitic.  The  inflation  was 
continued  until  the  stomach  became  distended  and  gas  escaped  by  eructation. 
The  subject  of  the  experiment  complained  of  quite  severe  colicky  pains  as 
long  as  the  small  intestines  remained  distended  by  gas. 

Exjjeriment  52.  The  writer  of  this  paper,  being  desirous  of  experiencing 
himself  the  sensations  which  would  be  caused  by  inflation  of  hydrogen  gas, 
submitted  himself  to  experimentation  under  a  pressure  of  one-half  pound  (.2 
kilogram).  Nearly  six  litres  of  gas  were  inflated  per  rectum.  The  distention 
of  the  colon  caused  simply  a  feeling  of  distention  along  its  course,  but  as 
soon  as  the  gas  escaped  into  the  ileum  colicky  pains  were  experienced,  which 
increased  as  insufliation  advanced,  and  only  ceased  after  all  the  gas  had 
escaped,  an  hour  and  a  half  later.  When  the  intestines  and  the  stomach  had 
become  fully  distended,  the  feeling  of  distention  was  distressing,  and  was 
attended  by  a  sensation  of  faintness  which  caused  a  profuse  clammy  perspi- 
ration. A  great  deal  of  the  gas  escaped  by  eructation,  which  was  followed 
by  great  relief.  The  colicky  pain  attending  inflation  of  the  small  intestines  by 
air  or  gas,  was  evidently  caused  by  increased  peristaltic  action  of  the  bowels 
in  their  attempt  to  expel  their  contents,  as  it  always  assumed  an  intermittent 
type  and  subsided  promptly  after  the  escape  of  the  gas. 

In  none  of  these  experiments  did  the  pressure  in  overcoming 
the  resistance  offered  by  the  ileo-csecal  valve  exceed  one  pound  (.45 
kilogram),  and  often  a  steady,  long-continued  pressure  of  one-fourth 
or  one -third  of  a  pound  (.1  to  .15  kilogram)  sufficed.  Every  time 
the  ileo-caecal  valve  was  rendered  incompetent  by  distention  of  the 
cfficum,  the  pressure  was  promptly  diminished  owing  to  the  escape 
of  gas  from  the  colon  into  the  ileum.  In  the  experiment  where  the 
inflation  was  made  in  a  case  of  typhlitis,  the  ileo-csecal  valve  offered 
no  resistance,  and  the  gas  escaped  freely  into  the  ileum.  The  valve 
in  all  probability  had  been  rendered  partially  or  completely  incom- 
petent during  the  course  of  local  inflammation,  or  the  indurated, 
thickened  walls  of  the  caecum,  when  distended  during  the  inflation, 
were  better  adapted  to  effect  incompetency  of  the  valve.      These 


238  INTESTINAL  SURGERY. 

experiments  also  furnish  strong  proof  of  the  fact  that  inflation,  to  be 
safe  and  effective,  should  be  done  very  slowly  under  a  low,  steady 
pressure,  continued  only  for  a  short  time;  and  is  attended  by  no 
risks  whatever  of  rupturing  a  healthy  intestine  and,  when  cautiously 
practiced,  can  be  resorted  to  even  in  cases  where  the  resisting 
power  of  the  intestinal  wall  has  been  diminished  by  antecedent 
pathological  processes. 

As  I  was  searching  for  an  innocuous,  non-irritating  gas  which, 
when  inflated  into  the  gastro-intestinal  canal,  would  escape  into  the 
peritoneal  cavity  in  case  a  wound  or  perforation  existed,  and  had 
decided  on  trying  hydrogen  gas,  it  became  necessary  to  study 
experimentally  the  efPect  of  this  gas  on  the  different  tissues  of  the 
living  body.  The  numerous  inflation  experiments  on  man  and  dogs 
have  demonstrated  the  safety  of  pure  hydrogen  gas  when  employed 
in  this  manner,  as  not  in  a  single  instance  were  any  immediate  or 
remote  toxic  symptoms  observed  which  could  be  referred  to  absorp- 
tion of  the  gas;  hence  we  have  the  assurance  that  the  inflation  of  a 
large  quantity  of  hydrogen  gas  is  unattended  by  any  risk  whatever 
as  far  as  intoxication  is  concerned.  The  following  experiments 
also  show  the  innocuity  and  non-irritating  qualities  of  hydrogen  gas 
when  brought  in  contact  with  the  tissues  most  susceptible  to  inflam- 
matory reaction  in  the  living  body;  at  the  same  time  they  show  that 
hydrogen  gas  is  removed  by  absorption  in  a  comparatively  short 
time,  when  injected  into  serous  cavities  or  into  the  subcutaneous 
connective  tissue: 

IV.    Hydrogen  Gas  is  Innocuous  and  Non-Irritating  when 

Brought  in  Contact  with  Living  Tissues  and  is 

Promptly  Removed  hy  Absorption. 

I.    Peritoneal  Cavity. 

Experiment  53.  Dog,  weight  forty-five  pounds.  A  circumscribed  spot  to 
the  right  of  the  linea  alba  was  shaved  and  thoroughly  disinfected,  and  through 
this  space  a  well  disinfected,  medium  sized  trocar  was  plunged  into  the  peri- 
toneal cavity.  To  the  cannula  of  the  trocar  the  rubber  tube  of  the  inflation 
balloon  charged  with  hydrogen  gas  was  attached,  and  the  whole  peritoneal 
cavity  filled  with  gas  by  compressing  the  balloon.  About  four  litres  of  gas 
were  injected.  No  gas  escaped  upon  the  withdrawal  of  the  cannula  and  the 
puncture  was  sealed  with  cotton  and  iodoform  coUodium.  The  animal 
appeared  to  sufifer  but  little  pain,  and  the  next  day  the  tympanites  had  dis- 
appeared and  the  dog  was  as  frisky  and  lively  as  before  the  inflation.      Two 


RECTAL  INSUFFLATION  IN  GUNSHOT    WOUNDS.  239 

days  after  the  experiment  was  made  the  dog  was  killed  and  the  peritoneal 
cavity  carefully  examined.  Not  a  trace  of  the  gas  remained  and  the  peritoneum 
throughout  presented  a  normal  appearance. 

2.    Pleural  Cavity. 

Experiment  54.  Dog,  weight  twenty-five  pounds.  After  thorough  dis- 
infection, an  aseptic  hollow  needle  was  inserted  between  the  seventh  and 
eighth  ribs  in  the  axillary  line  into  the  left  pleural  cavity,  and  hydrogen  gas 
from  rubber  balloon  forced  through  it  until  the  pleural  cavity  was  thoroughly 
distended.  On  making  a  physical  examination  of  the  chest  at  this  time  the 
apex  of  the  heart  was  found  to  the  right  of  the  sternum;  vesicular  breathing 
on  left  side  absent;  abnormal  resonance  on  percussion  of  this  side.  The  res- 
pirations became  superficial  and  greatly  increased  in  frequency.  On  with- 
drawing the  needle  no  gas  escaped  externally,  but  a  circumscribed  subcutaneous 
emphysema  which  appeared,  showed  that  some  of  the  gas  had  escaped  through 
the  puncture  in  the  pleura  into  the  subcutaneous  connective  tissue.  Twenty- 
four  hours  after  the  inflation  the  dog  appeared  to  be  in  perfect  health.  The 
normal  relations  in  the  chest  had  become  restored  and  the  subcutaneous 
emphysema  was  less  extensive.  The  animal  was  kept  under  observation  for 
a  considerable  length  of  time,  but  at  no  time  could  symptoms  of  pleuritis  be 
detected. 

3.    Subcutaneous  Cellular  Tissue. 

Experiment  55.  Old  dog,  weight  forty-three  pounds.  A  small,  perfectly 
aseptic  trocar  was  inserted  through  the  skin  into  the  loose  cellular  tissue  in 
the  right  inguinal  region,  and  through  the  cannula  two  litres  of  gas  were 
injected,  the  gas  distributing  itself  through  the  loose  connective  tissue  over 
a  large  surface  of  the  body.  Upon  the  withdrawal  of  the  cannula  the  puncture 
was  hermetically  sealed  with  iodoform  collodium  and  cotton.  The  subcuta- 
neous emphysema  disappeared  completely  in  forty-eight  hours,  and  no  traces 
of  inflammation  could  be  found  at  the  point  of  puncture,  or  at  any  place 
where  the  gas  had  come  in  contact  with  the  tissues. 

Experiment  56.  Dog,  weight  twenty-five  pounds.  Subcutaneous  inflation 
of  two  litres  of  hydrogen  gas  through  the  cannula  of  a  small  trocar  into  the 
left  side  of  the  chest.  The  subcutaneous  emphysema  reached  from  the  clavicle 
and  axilla  on  that  side  to  the  crest  of  the  ilium,  the  gas  at  some  points  elevat- 
ing the  skin  at  least  four  inches  from  the  subjacent  tissues.  The  gas  was 
absorbed  somewhat  more  slowly  than  in  the  preceding  experiment,  but  three 
days  after  the  inflation  no  trace  of  emphysema  could  be  detected,  and  the 
subcutaneous  connective  tissue  was  as  pliable  and  movable  as  before  the 
inflation. 

T.    Rectal  Insufflation  of  Hydrogen  Gas  in  the  Diagnosis 
of  Penetrating  Gunshot  Wounds  of  the  Ahdonien. 

In  these  experiments  the  animals  were  strapped  on  one   of 
Pasteur's  operating  tables.     Abdomen  shaved,  and  after  complete 


240  INTESTINAL  SURGERY. 

etherization  the  shooting  was  done  at  short  range  with  a  thirty-two 
calibre  revolver.  Inflation  of  hydrogen  gas  was  practiced  immedi- 
ately after  the  shot  was  fired,  and  after  its  diagnostic  value  was 
carefully  studied,  the  abdomen  was  opened  and  its  contents  exam- 
ined for  visceral  injuries.  In  all  cases  where  the  colon  was  perforated, 
inflation  could  be  done  under  very  slight  pressure,  as  the  gas  readily 
escaped  into  the  peritoneal  cavity,  and  from  there  through  the  bullet 
wound  in  the  abdominal  wall,  where  it  was  ignited  as  it  escaped.  As 
it  is  not  my  object  at  present  to  give  the  result  of  the  operative  treat- 
ment, the  experiments  will  only  be  described  in  reference  to  diagnosis 
as  verified  by  abdominal  section;  but  in  every  case  an  attempt  was 
made  to  save  the  life  of  the  animal  by  operative  treatment,  and  in  a 
few  instances  the  efforts  were  rewarded  by  success. 

Experiment  57,  Dog,  weight  thirty  pounds.  The  abdomen  was  opened 
by  an  incision  through  the  linea  alba  and  a  coil  of  the  small  intestine  was 
drawn  forward  into  the  wound,  and  an  incision  half  an  inch  (13  mm.)  in 
length  was  made  on  the  convex  side  and  the  intestine  returned.  A  small  glass 
tube  was  inserted  into  lower  angle  of  wound,  and  the  rest  of  the  wound  closed 
by  sutures.  About  two  litres  of  hydrogen  gas  were  inflated  per  rectum,  when 
the  gas  escaped  through  the  glass  tube,  and  when  ignited  burned  with  a 
continuous  steady  blue  flame  as  long  as  the  inflation  was  continued.  The 
wound  was  opened  and  a  small  quantity  of  gas  was  found  in  the  peritoneal 
cavity.  The  whole  intestinal  tract  below  the  visceral  wound  was  found 
moderately  distended  by  gas,  while  above  the  wound  the  intestine  was  normal 
in  size. 

Experiment  58.  Dog,  weight  fifteen  pounds.  When  the  dog  was  com- 
pletely under  the  influence  of  ether,  hydrogen  gas  was  forced  from  anus  to 
mouth,  and  while  the  abdomen  was  still  moderately  distended  the  animal  was 
shot  in  the  abdomen,  the  bullet  being  directed  transversely  from  the  point  of 
entrance  on  the  side  of  the  abdomen  two  inches  (5  cm.)  to  the  right  of  the 
median  line,  and  on  a  level  with  the  umbilicus.  On  appliying  a  lighted  taper 
to  wound  of  entrance,  and  compressing  the  abdomen,  hydrogen  gas  escaped 
and  was  ignited.  When  the  inflation  was  resumed  the  gas  burned  with  a 
continuous  flame  at  the  wound  of  entrance.  The  abdomen  was  then  opened 
and  two  perforations  in  the  stomach  were  found,  one  on  the  anterior  surface 
near  the  pylorus,  and  the  other  on  posterior  surface  at  the  cardiac  extremity, 
about  an  inch  above  the  omental  attachment.  The  distention  of  the  stomach 
by  hydrogen  gas  had  brought  this  organ  within  range  of  the  track  of  the 
bullet. 

Experiment  59.  Dog,  weight  twenty  pounds.  Under  complete  anaesthesia 
the  animal  was  shot  in  the  abdomen,  the  bullet  taking  the  same  direction  as  in 
the  previous  experiment,  only  that  the  track  was  about  an  inch  (2.5  cm.) 
above  the  umbilicus.      Immediately   after  the   shooting  hydrogen  gas   was 


RECTAL  INSUFFLATION  IN  GUNSHOT   WOUNDS.  241 

inflated  per  rectum,  and  its  presence  in  the  abdominal  cavity  became  evident 
by  a  marked  tympanites,  absence  of  liver  dullness,  and  later  by  a  localized 
emphysema  around  the  wound  of  entrance.  As  the  pressure  was  continued 
bubbles  of  gas  escaped,  and  on  applying  a  lighted  taper,  ignited  with  a  feeble 
explosive  report.  The  abdomen  was  opened,  and  the  stomach  showed  two 
perforations,  one  just  above  the  omental  attachment  near  the  pylorus,  and  the 
other  on  the  same  level  at  the  cardiac  extremity.  Little  haemorrhage,  and  no 
extravasation  of  contents  of  stomach. 

Experiment  60.  Dog,  weight  thirty  pounds.  Animal  anaesthetized  and  shot 
in  abdomen  at  a  range  of  two  feet;  wound  of  entrance  two  inches  to  the  right 
of,  and  on  a  level  with  the  umbilicus.  Wound  of  exit  one  inch  above  the 
middle  of  left  crest  of  ilium.  Inflation  of  hydrogen  gas  per  rectum  soon 
caused  extensive  tympanites,  and  as  but  little  force  had  been  used,  the  con- 
clusion was  drawn  that  some  part  of  the  descending  colon  had  been  injured. 
As  the  gas  did  not  readily  escape  through  the  bullet  wounds,  a  small  cannula 
was  inserted  into  the  abdominal  cavity  through  the  wound  of  entrance,  when 
the  gas  escaped  freely  and  was  ignited.  On  opening  the  abdomen  examination 
revealed  the  following  visceral  injuries:  Two  perforations  in  the  descending 
colon;  four  in  the  ileum,  within  a  distance  of  ten  inches  of  the  ileo-csecal 
valve;  eight  in  the  upper  part  of  the  ileum,  within  the  space  of  one  foot 
(30.5  cm.)  of  the  intestine.  The  mesentery  was  perforated  at  three  points, 
and  a  number  of  mesenteric  vessels  of  considerable  size  were  severed,  which 
gave  rise  to  profuse  haemorrhage. 

Experiment  61.  Large  coach  dog.  The  animal  was  completely  etherized, 
and  shot  in  the  abdomen  at  close  range.  Wound  of  entrance  midway  between 
linea  alba  and  vertebral  column  on  left  side,  a  little  below  the  level  of  the 
umbilicus;  wound  of  exit  close  to  the  last  lumbar  vertebra  over  crest  of  ilium 
on  opposite  side.  Rectal  inflation  of  hydrogen  gas  undor  slight  pressure  at 
once  produced  diffuse  tympanites,  and  the  gas  escaped  freely  through  wound 
of  entrance,  where  it  was  ignited  and  burned  with  a  large  steady  blue  flame 
as  long  as  the  inflation  was  continued.  On  opening  the  abdomen  gas  escaped, 
but  inspection  showed  that  the  small  intestines  contained  no  gas,  a  condition 
which  pointed  to  the  colon  as  the  seat  of  perforation.  One  perforation  was 
found  in  the  anterior  wall  of  the  sigmoid  flexure,  and  two  perforations  in  the 
caecum.  In  the  small  intestines  two  perforations  were  found  in  the  ileum  near 
the  caecum,  and  three  in  the  upper  portion  of  the  jejunum.  Among  the  other 
organs  injured  were  the  spleen,  and  the  receptaculum  chyli;  a  number  of  per- 
forations were  found  in  the  mesentery. 

Experiment  62.  Large  dog.  Profound  ether  narcosis.  Shot  in  the  abdo- 
men, the  bullet  entering  on  a  level  with  the  umbilicus  and  about  one  inch  to 
the  left  of  the  median  line.  Point  of  exit  two  inches  from  spinal  column, 
and  a  little  above  the  lower  border  of  the  chest.  On  inflating  the  rectum  with 
hydrogen  gas,  hardly  any  force  was  required  to  distend  the  abdomen,  and  for 
this  reason  it  was  believed  that  the  colon  in  some  part  of  its  course  had  been 
injured.  Gas  escaped  readily  through  the  wound  of  entrance,  where  it  was 
lighted  and  burned  with  the  characteristic  blue  flame.  The  abdomen  when 
16 


242  INTESTINAL  SURGERY. 

opened  was  found  almost  completely  filled  with  blood.  The  source  of  this 
profuse  haemorrhage  was  the  right  kidney  which  showed  a  perforation  through 
the  centre.  An  examination  of  the  gastro-intestinal  canal  revealed  two 
perforations  of  the  caecum,  and  five,  of  the  small  intestines.  After  passing 
through  the  kidney  the  bullet  perforated  the  diaphragm,  traversed  the  pleural 
cavity,  and  escaped  through  the  chest  wall  two  inches  (5  cm.)  to  the  right  of 
the  spine. 

Experiment  63.  Old  dog,  weight  thirty-five  pounds.  Thoroughly  etherized 
and  shot  in  the  abdomen,  the  bullet  entering  three  inches  (7.6  cm.)  to  the  right 
of,  and  an  inch  and  a  half  (3.8  cm.)  below  the  umbilicus,  passing  almost  trans- 
versely through  the  abdominal  cavity  and  escaping  ai  a  corresponding  point 
on  left  side.  Inflation  of  hydrogen  gas  was  attempted,  but  failed  on  account 
of  the  apparatus  being  out  of  order.  The  abdomen  was  opened  and  no  gas 
was  found  even  in  the  colon.  Twelve  perforations  of  the  small  intestines  were 
found,  and  a  number  of  perforations  of  the  mesentery,  which  had  caused  pro- 
fuse haemorrhage. 

Experiment  64.  Large,  black  dog.  Etherized  and  shot  in  the  abdomen; 
wound  of  entrance  three  inches  (7.6  cm.)  to  the  right  of,  and  an  inch  and  a 
half  below  the  umbilicus;  wound  of  exit  near  a  corresponding  point  on 
opposite  side,  the  bullet  taking  nearly  a  transverse  course.  Rectal  inflation  of 
hydrogen  gas  gave  a  prompt  positive  result.  The  abdomen  was  opened  and 
five  perforations  of  small  intestine  were  found,  besides  laceration  of  thoracic 
duct,  and  a  number  of  perforations  in  mesentery.  Colon  and  small  intestine 
below  the  lowest  point  of  perforation  contained  gas,  while  above  the  lowest 
perforation  the  bowel  contained  no  gas. 

Experiment  65,  Dog,  weight  twenty-five  pounds.  Under  full  anaesthesia 
the  animal  was  shot  in  the  abdomen,  the  bullet  passing  in  a  nearly  transverse 
direction  through  the  abdominal  cavity  an  inch  and  a  half  below  the  umbilicus 
from  point  of  entrance;  wound  of  exit  midway  between  linea  alba  and  spine. 
Rectal  insufilation  of  hydrogen  gas  made  under  very  low  pressure,  led  to 
rapid  distention  of  the  abdomen,  an  occurrence  which  furnished  strong 
evidence  that  the  gas  had  escaped  through  a  perforation  in  the  colon  into  the 
peritoneal  cavity.  The  gas  escaped  in  bubbles  through  the  wound  of  entrance? 
and  when  a  lighted  taper  was  held  near  the  wound,  it  burned  with  a  jet  vary- 
ing in  size.  On  opening  the  abdomen  gas  escaped  from  the  peritoneal  cavity; 
small  intestines  empty,  and  only  a  small  amount  of  gas  in  the  colon.  The 
following  intra-peritoneal  injuries  were  found:  Four  perforations  of  the 
duodenum,  two  of  the  jejunum,  and  one  of  the  caecum;  also  a  perforation 
nearly  through  the  centre  of  the  left  kidney,  laceration  of  the  receptaculum 
chyli,  and  a  number  of  perforations  in  the  mesentery.  The  bullet  was  found 
between  the  left  kidney  and  the  abdominal  wall. 

In  all  of  these  experiments  the  bullet  was  fired  through  the 
abdomen  from  side  to  side  transversely,  or  somewhat  obliquely, 
directions  which  invariably  brought  into  the  track  of  the  bullet  a 
number  of  intestinal  coils,  and  often  the  colon.      In  the  two  experi- 


RECTAL  INSUFFLATION  IN  GUNSHOT  WOUNDS.  243 

ments  where  the  track  of  the  bullet  was  a  little  higher  up,  the 
intestines  escaped,  but  the  stomach  showed  two  perforations,  one 
near  the  pyloric,  and  the  other  near  the  cardiac  extremity.  Rectal 
insufflation  of  hydrogen  gas  proved  an  infallible  test  in  every 
instance,  except  in  the  case  where  it  failed  on  account  of  the  infla- 
tion apparatus  being  out  of  order.  Contrary  to  the  experience  of 
other  experimenters,  x  found  that  fsecal  extravasation  does  not 
uniformly  take  place  soon  after  gunshot  wounds  of  the  intestines; 
in  the  cases  where  I  observed  it,  some  part  of  the  colon  had  been 
wounded.  Intestinal  inflation  does  not,  therefore,  tend  to  increase 
the  frequency  of  this  occurrence,  and  must,  on  this  account,  be 
looked  upon  as  a  harmless  measure. 

Inflation,  as  a  preliminary  measure,  greatly  expedites  the  first 
step  in  the  operation  of  abdominal  section  in  cases  where  the  intes- 
tine has  been  perforated  or  injured,  as  the  gas  which  escapes  into 
the  peritoneal  cavity  separates  the  intestines  from  the  anterior 
abdominal  wall,  and  the  incision  can  be  made  safely  and  rapidly 
without  fear  of  wounding  the  intestines.  Penetrating  wounds  of 
the  abdomen,  where  the  course  of  the  bullet  is  in  an  opposite  direc- 
tion to  that  which  has  been  described  in  the  preceding  experiments, 
that  is,  in  an  antero-posterior  direction,  may  not  implicate  the  intes- 
tines at  all ;  or  if  visceral  injury  is  inflicted,  it  is  more  likely  that 
only  a  single  perforation  exists,  and  never  does  the  surgeon  meet 
with  such  a  multiplicity  of  lesions  as  have  been  cited  above.  Unless 
the  surgeon  can  ascertain  beforehand,  that  in  a  case  of  penetrating 
wound  of  the  abdomen  an  injury  to  some  portion  of  the  gastro- 
intestinal canal  exists,  the  very  means  which  he  resorts  to  in  making 
an  anatomical  diagnosis  is  often  an  imminent  source  of  danger,  as 
only  too  often  he  may  have  to  examine  every  inch  of  the  gastro- 
intestinal canal  for  this  purpose,  a  procedure  which  is  always 
attended  by  great  risk  to  life.  If  by  such  a  simple  and  harmless 
procedure  as  insufflation  of  hydrogen  gas,  he  can  satisfy  himself 
that  the  gastro-intestinal  canal  is  perforated,  the  course  to  pursue 
becomes  clear — to  open  the  abdomen,  seek  for  the  perforation  until 
he  finds  it,  and  adopt  proper  treatment  for  the  visceral  injury. 

Cases  have  also  happened  in  which  the  operator  opened  the 
abdomen,  sought  for,  found  and  treated  one  or  more  perforations 
and,  on  making  the  autopsy  a  day  or  two  later  found,  to  his  great 
chagrin  and  sorrow,  a  perforation  which  he  had  overlooked  at  the 


244  INTESTINAL  SURGERY. 

time  of  operation.  It  seems  to  me  that  in  cases  in  which  any  doubt 
exists  as  to  the  integrity  of  the  remaining  portion  of  the  intestinal 
canal,  after  closing  one  or  more  perforations,  it  would  be  advisable 
to  search  for  additional  perforations  by  resorting  again  to  slow  and 
careful  inflation  before  the  abdominal  wound  is  closed.  If  no  other 
perforations  exist  the  gas  will  be  confined  to  the  interior  of  the 
gastro-intestinal  canal,  and  if  the  stomach  or  intestines  at  some  point 
difficult  of  access  are  injured,  the  leakage  of  gas  through  the  perfo- 
rations will  lead  the  surgeon  to  the  wound. 

In  the  practical  application  of  rectal  insufflation  of  hydrogen 
gas,  as  a  means  of  diagnosis  in  penetrating  wounds  of  the  abdomen, 
the  field  of  possible  operation  should  be  carefully  prepared  by  shav- 
ing and  disinfection  before  inflation.  After  thorough  disinfection  of 
the  external  wound  or  wounds,  and  the  field  of  operation,  the  patient 
should  be  placed  thoroughly  under  the  influence  of  an  anaesthetic 
for  the  purpose  of  relaxing  the  abdominal  muscles,  which  greatly 
facilitates  the  inflation. 

In  the  absence  of  a  Wolf's  bottle,  hydrogen  gas  can  be  readily 
generated  in  a  large  wide-mouthed  bottle  into  which  a  small  handful 
of  chips  of  pure  zinc  is  placed.  The  mouth  of  the  bottle  is  closed 
with  a  cork  with  two  perforations,  through  which  two  glass  tubes  are 
inserted,  one  for  the  purpose  of  pouring  in  water  and  sulphuric  acid, 
and  the  other,  which  should  be  bent  nearly  at  right  angles,  for  lead- 
ing away  the  gas.  This  glass  tube  and  a  rubber  balloon  with  a 
capacity  of  sixteen  litres  of  gas  are  connected  by  means  of  a  rubber 
tube.  In  from  five  to  ten  minutes  the  requisite  amount  of  gas  can 
be  generated  and  everything  is  ready  for  the  inflation.  The  rubber 
tube  connecting  the  balloon  with  the  rectal  tip  of  an  ordinary 
syringe  should  be  interrupted  by  a  stop-cock,  so  that  the  escape  of 
gas  can  be  prevented  whenever  inflation  is  temporarily  suspended. 
The  return  of  gas  along  the  sides  of  the  rectal  tip  can  be  readily 
prevented  by  an  assistant  pressing  the  anal  margins  firmly  against  it. 

The  inflation  must  always  he  made  slowly,  as  long  continued, 
uninterrupted  pressure  accomplishes  most  effectually  lateral  and 
longitudinal  dilatation  of  the  ccecum ;  conditions  which  render  the 
ileo-csecal  valve  incompetent,  and  which  must  be  secured  before 
inflation  of  the  small  intestines  is  possible.  The  entrance  of  gas 
from  the  colon  into  the  ileum  is  always  attended  by  a  diminution  of 


RECTAL  INSUFFLATION  IN  GUNSHOT   WOUNDS.  245 

pressure,  and  its  occurrence  can  invariably  be  recognized  by  a 
gurgling  or  blowing  sound  over  the  ileo-csecal  valve,  sometimes 
sufficiently  loud  to  be  heard  at  some  distance. 

If,  after  inflation,  abdominal  distention  and  tympanites  be  from 
the  very  first  diffuse,  and  liver  dullness  has  disappeared,  it  is  a 
certain  indication  that  they  are  due  to  the  presence  of  gas  in  the 
peritoneal  cavity,  and  not  to  distention  of  the  gastro- intestinal 
canal.  If,  on  the  other  hand,  the  distention  and  tympanites  follow 
the  course  of  the  colon,  and  after  the  entrance  of  the  gas  through 
the  ileo-csecal  valve,  are  circumscribed  and  limited  to  the  umbilical 
and  hypogastric  regions,  and  gradually  extend  to  the  upper  portion 
of  the  abdomen,  and  the  liver  dullness  is  displaced  upicards,  they  are 
in  all  probability  caused  by  a  gradual  and  successive  inflation  of  the 
intact  bowel  in  an  upward  direction. 

In  some  penetrating  wounds  of  the  abdomen  it  is  difficult,  if 
not  impossible  to  follow  the  course  of  the  bullet  through  the  abdom- 
inal wall  with  a  probe  or  finger,  on  account  of  the  relative  change  of 
position  of  the  different  layers  of  tissues  in  the  track  of  the  biillet, 
obliterating  the  canal ;  but  even  in  these  cases  a  moderate  distention 
of  the  peritoneal  cavity  by  an  accumulation  of  gas  outside  of  the 
intestines,  will  force  bubbles  of  gas  through  the  tortuous  canal.  By 
this  sign  the  surgeon  may  know  positively  that  some  portion  of  the 
gastro-intestinal  canal  has  been  perforated;  and  in  order  to  prove 
that  the  bubbles  which  escape  are  part  of  the  hydrogen  gas  which 
has  been  inflated,  he  applies  a  lighted  match  or  taper.  If  it  is 
hydrogen  gas  it  will  ignite  with  a  slight  explosive  report,  and  burn 
with  a  characteristic  blue  flame.  The  burning  of  the  escaping 
hydrogen  gas  on  the  surface  of  the  external  wound  is  a  most  effective 
means  in  securing  for  the  wound  an  aseptic  condition,  and  on  that 
account,  the  escaping  gas  should  be  lighted,  both  for  diagnostic  and 
therapeutic  purposes,  in  all  cases  in  which  rectal  insufflation  of 
hydrogen  gas  reveals  the  presence  of  visceral  injuries  of  the  gastro- 
intestinal canal. 

As  hydrogen  gas  from  its  low  specific  gravity  will  always  occupy 
the  highest  space  in  a  cavity  partially  filled  with  fluids,  it  is  neces- 
sary to  place  the  external  abdominal  wound  in  such  a  position  that 
blood  or  any  other  fluid  that  may  be  present  in  the  abdominal  cavity 
will  not  interfere  with  its  ready  escape.     If  the  wound  is  anterior 


246  INTESTINAL  SURGERY. 

the  patient  must  be  placed  in  the  dorsal  position ;  if  lateral,  on  the 
opposite  side,  during  the  inflation.  If  during  inflation,  early  and 
diffuse  tympanites  takes  place,  it  speaks  in  favor  of  perforation  of 
the  colon. 

Should  the  external  wound  prevent  the  escape  of  gas  from  the 
peritoneal  cavity,  by  sliding  of  the  different  layers  of  tissue  of  the 
wound  in  the  abdominal  wall,  or  by  the  presence  of  a  coagulum  in 
the  track  made  by  the  bullet,  it  becomes  necessary  to  secure  a  suffi- 
cient degree  of  patency  of  the  wound  for  the  escape  of  gas,  by  careful 
probing  or  the  removal  of  coagulated  blood.  The  finding  of  perfo- 
rations is  also  greatly  facilitated  by  inflation,  as  the  bowel  below  the 
lowest  perforation  will  always  be  found  at  least  slightly  dilated  by 
gas.  If  this  perforation  is  now  closed  and  additional  perforations 
are  suspected  to  exist,  the  inflation  can  be  repeated,  and  the  bowel 
will  again  become  distended  as  far  as  the  next  perforation,  and  this 
process  can  be  repeated  until  the  entire  intestinal  canal  has  been 
examined.  By  searching  for  leaking  points  in  this  manner,  but  little 
manipulation  of  the  intestines  becomes  necessary,  and  thus  one  of 
the  great  sources  of  danger  in  the  operative  treatment  of  wounds  or 
perforations  of  the  gastro-intestinal  canal  is  avoided. 

The  moderate  distention  of  the  intestines  left  after  treating  the 
visceral  wounds,  never  interfered  with  the  return  of  the  intestines 
into  the  abdominal  cavity  or  the  closure  of  the  external  wound  in 
any  of  the  experiments;  and  the  numerous  observations  made  in 
reference  to  the  disappearance  of  the  gas  by  absorption,  or  escape 
through  the  natural  outlets,  are  conclusive  in  showing  that  the  dis- 
tention due  to  the  presence  of  the  gas  disappears  in  a  remarkably 
short  time.  It  can  therefore  be  safely  stated  that  rectal  insufilation 
of  hydrogen  gas  in  the  diagnosis  and  treatment  of  penetrating 
wounds  of  the  abdomen,  does  not  interfere  with  an  ideal  healing  of 
the  visceral  and  laparotomy  wounds. 

After  a  careful  study  of  the  subject  of  rectal  insufflation  of 
hydrogen  gas  in  its  various  aspects,  I  do  not  hesitate  to  recommend 
its  adoption  in  practice  as  an  infallible  diagnostic  test  in  demon- 
strating the  existence  of  a  wound  of  the  gastro-intestinal  canal  in 
penetrating  wounds  of  the  abdomen,  or  perforations  from  any  other 
cause,  without  resorting  to  an  exploratory  laparotomy. 


CONCLUSIONS.  247 

In  conclusion  I  beg  leave  to  submit  the  following  propositions : 

1.  The  entire  alimentary  canal  is  permeable  to  rectal  insuffla- 
tion of  air  or  gas. 

2.  Inflation  of  the  entire  alimentary  canal  from  above  down- 
wards through  a  stomach  tube  seldom  succeeds,  and  should  there- 
fore only  be  resorted  to  in  demonstrating  the  presence  of  a  perforation 
or  wound  of  the  stomach,  and  for  locating  other  lesions  in  the  organ 
or  its  immediate  vicinity. 

3.  The  ileo-csecal  valve  is  rendered  incompetent  and  permea- 
ble, by  rectal  insufflation  of  air  or  gas  under  a  pressure  varying 
from  one -fourth  of  a  pound  to  two  pounds. 

4.  Air  or  gas  can  be  forced  through  the  whole  alimentary 
canal  from  anus  to  mouth,  under  a  pressure  varying  from  one-third 
of  a  pound  to  two  pounds  and  a  half. 

5.  Rectal  insufflation  of  air  or  gas  to  be  both  safe  and  effective 
must  be  done  very  slowly  and  without  interruptions. 

6.  The  safest  and  most  effective  rectal  insufflator  is  a  rubber 
balloon  large  enough  to  hold  sixteen  litres  of  air  or  gas. 

7.  Hydrogen  gas  should  be  preferred  to  atmospheric  air  or 
other  gases  for  purposes  of  inflation  in  all  cases  where  this  pro- 
cedure is  indicated. 

8.  The  resisting  power  of  the  intestinal  wall  is  nearly  the 
same  throughout  the  entire  length  of  the  canal,  and  in  a  normal 
condition  yields  to  diastaltic  force  of  from  eight  to  twelve  pounds  of 
pressure.  When  rupture  takes  place  it  either  occurs  as  a  longitudi- 
nal laceration  of  the  peritoneum  on  the  convex  surface  of  the  bowel, 
or  as  miiltiple  ruptures  from  within  outwards,  at  the  mesenteric 
attachment.  The  former  result  follows  rapid,  and  the  latter  slow 
inflation. 

9.  Hydrogen  gas  is  devoid  of  toxic  properties,  non-irritating 
when  brought  in  contact  with  living  tissues,  and  rapidly  absorbed 
from  the  connective  tissue  spaces  and  all  of  the  large  serous  cavities. 

10.  The  escape  of  air  or  gas  through  the'ileo-csecal  valve  from 
below  upwards  is  always  attended  by  a  blowing  or  gurgling  sovmd, 
heard  most  distinctly  over  the  ileo-csecal  region,  and  by  a  sudden 
diminution  of  pressure. 


248  INTESTINAL  SURGERY, 

11.  The  incompetency  of  the  ileo-csecal  valve  is  caused  by  a 
lateral  and  longitudinal  distention  of  the  caecum,  which  mechanically 
separates  the  margins  of  the  valve. 

12.  In  gunshot  or  punctured  wounds  of  the  gastro-intestinal 
canal,  insufflation  of  hydrogen  gas  enables  the  surgeon  to  demon- 
strate positively  the  existence  of  the  visceral  injury,  without  incur- 
ring the  risks  and  medico- legal  responsibilities  incident  to  an 
exploratory  laparotomy. 


INFLATION   OF  THE    STOMACH  WITH   HYDKOGEN 
GAS   IN   THE    DIAGNOSIS    OF    WOUNDS   AND 
PEKFOEATIONS  OF  THIS  OEGAN,  WITH 
THE    EEPOKT    OF   A    CASE.'      . 


In  my  paper  on  "Rectal  Insufflation  of  Hydrogen  Gas  as  an 
Infallible  Test  in  the  Diagnosis  of  Visceral  Injury  of  the  Gastro- 
intestinal Canal  in  Penetrating  Wounds  of  the  Abdomen,"  read  in 
the  Surgical  Section  of  the  American  Medical  Association,  I  inci- 
dentally called  the  attention  of  the  medical  profession  to  the  value 
of  inflation  of  the  stomach  as  a  diagnostic  measure,  in  cases  of  injury 
or  perforation  of  this  organ,  in  that  part  of  the  paper  which  treated 
of  inflation  of  the  alimentary  canal  through  the  stomach  tube.  We 
should  naturally  expect  that  the  alimentary  canal  could  be  inflated 
with  more  ease  and  with  a  less  degree  of  force  by  following  the  nor- 
mal peristaltic  wave.  That  this  is  not  the  case  can  be  seen  from  the 
experiments  given  in  detail  in  the  paper  referred  to. 

These  experiments  demonstrate  conclusively  that  it  is  more 
difficult  to  inflate  the  alimentary  canal  from  above  downward  than 
from  below  upward;  as  in  the  living  animal  I  succeeded  in  only  one 
instance  in  forcing  hydrogen  gas  from  the  mouth  to  the  anus,  while 
in  others,  a  degree  of  force  sufficient  to  rupture  the  peritoneal  coat 
of  the  stomach,  only  efPected  distention  of  the  stomach  and  upper 
portion  of  the  intestinal  canal.  It  is  evident  that  great  distention 
of  the  stomach  constitutes  an  important  factor  in  causing  or  aggra- 
vating intestinal  obstruction,  as  it  efPects  compression,  which  again 
causes  impermeability  of  the  intestines,  or  aggravates  conditions 
arising  from  an  antecedent  partial  permeability,  by  producing  sharp 
flexions  among  the  distended  coils  of  the  intestines. 

For  diagnostic  and  surgical  puri:)oses,  tfie  stomach  can  be 
readily  inflated  almost  to  any  extent  through  a  stomach  tube,  and 
when  it  becomes  necessary  to  ascertain  the  presence  of  a  visceral 

249 


250  INTESTINAL  SURGERY. 

wound  or  perforation  of  this  organ,  this  method  of  inflation  may  be 
resorted  to  with  advantage. 

I  have  recently  had  an  excellent  opportunity  to  apply  this  test 
in  a  case  of  gunshot  wound  of  the  chest  and  abdomen,  in  which, 
without  it,  it  would  have  been  impossible  to  make  a  correct  diagno- 
sis. The  insufflation  made  the  diagnosis  positive,  and  the  informa- 
tion obtained  from  it  justified  the  treatment  by  laparotomy,  although 
the  general  symptoms  were  so  grave  that  it  appeared  doubtful  if  the 
patient  would  live  long  enough  to  complete  the  operation. 

C.  H.,  seventy-two  years  of  age,  was  brought  to  the  Milwaukee  Hospital 
by  the  police  patrol,  at  7  a.m.,  July  9,  1888,  for  a  suicidal  pistol  (44-calibre 
bulldog)  wound  of  the  chest,  inflicted  about  two  hours  previously.  Pistol  held 
in  the  left  hand,  as  ascertained  from  the  patient  and  confirmed  subsequently 
by  examination  of  the  direction  of  the  bullet.  The  patient  stated  that  he  had 
pointed  the  pistol  toward  the  heart. 

Examination,  7  a.m.  Wound  of  entrance  situated  in  the  left  sixth  inter- 
costal space,  surrounded  by  emphysema.  Seventh  rib  fractured  at  junction 
of  cartilage  and  bone.  No  wound  of  exit.  Patient  conscious;  complains  of 
severe  pain  in  the  epigastric  region,  increased  by  pressure.  Pulse  rapid  and 
weak.  Vomits  and  expectorates  blood.  Area  of  liver  dullness  diminished. 
Percussion  and  respiratory  sounds  normal.  No  evidence  of  hsemo-  or 
pneumo-thorax. 

9  A.M.  Flexible  tube  introduced  and  stomach  inflated  with  hydrogen  gas 
from  a  four-gallon  rubber  balloon.  Inflation  effected  by  continuous  pressure 
on  the  balloon.  Gas  escaped  and  ignited  at  the  wound  of  entrance  with  an 
audible  sound.  Field  of  operation  thoroughly  disinfected.  Patient  etherized 
and  laparotomy  made  by  incision  from  the  ensiform  cartilage  to  the  umbilicus. 
The  omentum  and  stomach  were  drawn  forward  into  the  wound.  A  large 
perforation,  about  one  and  a  half  inches  in  length  (due  to  the  oblique 
direction  of  the  bullet),  was  found  in  the  stomach,  midway  between  the 
pylorus  and  the  cardiac  end,  on  the  greater  curvature.  Stomach  partially 
filled  with  coagulated  blood.  With  the  index  finger  introduced  through  this- 
perforation,  another  was  detected  on  the  lesser  curvature  and  near  the  cardiac 
end.  The  omentum,  which  was  adherent  to  the  colon,  was  torn  through  and 
exploration  of  the  posterior  surface  of  the  stomach  failed  to  reveal  the  old 
site  of  the  second  wound,  which  was  felt  by  the  digital  exploration  of  the 
interior  of  the  organ.  The  blood-clots  were  removed  from  the  stomach  by 
irrigation  through  the  lower  wound. 

For  the  purpose  of  locating  with  accuracy  the  second  wound,  the  stomach 
was  inflated  through  the  bullet  wound  on  the  anterior  surface  with  hydrogen 
gas,  the  escape  of  which  made  it  easy  to  locate  the  second  wound.  The 
omental  opening  was  enlarged  by  tearing,  and  the  perforation  was  discovered 
on  the  posterior  surface  at  the  lesser  curvature  and  close  to  the  cardiac  orifice. 
Great  diflBculty  was  experienced  in  dragging  the  stomach  sufficiently  forward 
and  downward  into  the  abdominal  incision  to  suture  the  perforation,  which 


INFLATION  OF  STOMACH  BY  HYDROGEN  GAS.  251 

was  two  inches  in  length.     It  was  closed  by  a  continuous  Lembert  suture  of 
silk,  the  anterior  wound  by  a  Czerny -Lembert  suture. 

Considerable  blood  was  found  behind  the  stomach,  in  the  region  of  the 
pancreas.  The  haemorrhage  had  evidently  taken  place  from  lacerated  vessels 
of  considerable  size  at  both  perforations,  as  well  as  from  vessels  in  the  pro- 
peritoneal  space.  Probable  direction  of  the  bullet  from  above  downward, 
backward  and  to  the  right.  At  this  stage  collapse  from  shock  and  haemorrhage 
supervened.  The  body  was  partially  inverted  and  a  saline  infundation  of 
fifteen  ounces  of  a  six-tenths  per  cent,  salt  solution  performed.  Brandy  was 
injected  subcutaneously  and  the  faradic  current  applied  to  the  phrenic  and 
pneumogastric  nerves  without  any  apparent  effect.  Death  occurred  before 
the  abdominal  wound  could  be  closed. 

The  abdominal  incision  was  sutured  and  inflation  of  hydrogen  gas  per 
rectum,  made  to  test  the  condition  of  the  sutured  stomach.  A  stomach  tube 
waa  introduced  and  the  gas,  under  a  pressure  of  not  more  than  a  pound, 
forced  through  the  entire  gastro-intestinal  canal,  igniting  and  burning  with  a 
continuous  flame  as  it  escaped  from  the  end  of  the  stomach-tube,  which 
showed  that  no  gas  escaped  through  the  sutured  wounds.  Post-mortem  was 
made  immediately.  Wound  of  entrance  in  the  ^ixth  intercostal  space,  seventh 
rib  fractured  at  junction  of  cartilage  and  bone,  both  pleural  cavities  obliter- 
ated by  adhesions,  margin  of  lower  lobe  of  left  lung  perforated,  pericardium 
intact,  lacerated  opening  in  diaphragm  admitting  two  fingers.  Perforations 
in  stomach  as  described.  Liver  and  spleen  not  injured,  upper  margin  of  tail 
of  pancreas  lacerated.  Bullet  passed  to  the  left  of  the  aorta,  entered  the  left 
crus  of  the  diaphragm,  fractured  the  last  rib  at  the  neck  and  perforated  the 
spinal  column,  entering  between  the  last  dorsal  and  the  first  lumbar  vertebra, 
escaping  through  the  body  of  the  latter  and  fracturing  its  right  transverse 
process.  Bullet  found  in  the  subcutaneous  connective  tissue  of  right  lumbar 
region.  The  spinal  canal  was  opened  by  the  bullet  in  its  passage  through  the 
vertebra,  and  loose  fragments  of  bone  lay  in  the  canal.  The  membranes  of 
the  cord  were  intact  and  the  cord  itself  uninjured. 

The  location  of  the  wound  of  entrance  in  this  case,  did  not 
indicate  that  the  bullet  had  entered  the  abdominal  cavity,  unless  the 
revolver  was  held  in  the  left  hand;  in  that  case,  as  it  was  directed 
toward  the  heart,  the  track  of  the  bullet  would  be  necessarily  down- 
ward, backward  and  from  left  to  right.  Taking  it  for  granted  that 
the  bullet  took  this  direction,  it  would  still  have  been  possible 
for  the  stomach  to  escape  injury.  The  circmnscribed  emphysema 
around  the  external  wound  and  the  haemoptysis,  as  well  as  the 
location  of  the  wound,  left  no  doubt  that  the  lower  lobe  of  the  lung 
was  injured.  The  absence  of  haemothorax  and  pneumothorax  was 
explained  by  the  post-mortem,  as  the  left  pleural  cavity  was  found 
completely  obliterated  by  adhesions.  Under  a  pressure  of  not  more 
than  half  a  pound  to  the  square  inch,  the  hydrogen  gas  was  forced 


252  INTESTINAL  SURGERY. 

through  the  external  wound,  where  it  was  lighted  and  burned  in  a 
large  continuous  flame  until  it  was  extinguished  by  compression 
with  a  large  moist  sponge.  Very  little  gas  was  found  in  the 
peritoneal  cavity. 

In  perforation  of  the  stomach  without  an  external  wound,  infla- 
tion of  the  organ  with  hydrogen  gas  will  render  the  abdomen 
universally  tympanitic;  as  the  gas  will  escape  into  the  pe^-itoneal 
cavity  and,  as  it  always  occupies  the  highest  plane,  on  account  of  its 
low  specific  gravity,  it  will  push  the  abdominal  organs  backward. 
Thus  it  happens  that  the  liver  dullness  disappears  completely,  which 
fact  alone,  if  established,  makes  the  diagnosis  of  perforation  positive, 
unless  the  organ  is  fixed  in  its  place  by  peritoneal  adhesions,  the 
result  of  a  previous  peri-hepatitis. 

In  cases  of  perforating  ulcer  of  the  stomach  or  duodenum,  if 
this  simple  diagnostic  measure  is  resorted  to  in  time,  it  will  prove 
the  means,  by  prompt  surgical  treatment,  of  saving  many  a  life  that 
would  have  been  sacrificed  under  the  expectant  plan  of  treatment. 

It  has  been  claimed  that  hydrogen  gas  is  objectionable  for 
purposes  of  inflation,  as  when  it  is  mixed  with  a  certain  proportion 
of  oxygen  or  atmospheric  air  it  forms  an  explosive  compound. 
Against  this  argument  I  can  say  that  no  accidents  of  any  kind  have 
occurred  during  any  of  my  numerous  experiments  on  animals,  nor  in 
the  few  cases  in  which  it  has  been  applied  in  practice.  Hydrogen 
gas  has  the  lowest  specific  gravity  of  all  the  gases  known,  and  on 
this  account,  as  well  as  from  its  non-toxic  qualities,  it  should  always 
be  preferred  to  other  gases,  or  to  atmospheric  air  simple  or  medi- 
cated. The  hydrogen  gas  test,  if  successful,  appeals  both  to  the  sense 
of  sight  and  hearing  in  cases  of  perforating  wounds.  The  prepara- 
tion of  the  gas  is  so  simple  and  rapid  that  its  use  is  applicable  not 
only  in  hospital  and  city,  but  also  in  country  practice. 

I  have  recently  been  able  to  make  a  correct  diagnosis  in  several 
cases  of  obscure  abdominal  tumors,  by  resorting  to  stomach  and 
rectal  inflation  of  hydrogen  gas,  which,  without  these  diagnostic 
measures,  would  have  been  impossible,  short  of  exploratory  laparot- 
omy. The  relation  of  tumors  of  the  abdominal  cavity  to  the 
different  organs  and  the  peritoneal  cavity,  can  be  mapped  out  and 
studied  with  great  accuracy  by  dilating  the  stomach  and  different 
portions  of  the  intestinal  canal,  at  intervals,  by  inflation  with  this 
harmless  and  readily  procurable  gas. 


TWO  CASES  OF  GUNSHOT  WOUND  OF  THE  ABDO- 
MEN,   ILLUSTKATING   THE   USE  OF  EECTAL 
INSUFFLATION  WITH  HYDEOGEN  GAS 
AS   A  DIAGNOSTIC   MEASUEE.' 


Case  I.  J.  J.,  sixteen  years  of  age,  was  out  hunting  with  some  compan- 
ions, on  Sunday,  September  9,  1888,  one  of  whom  accidentally  discharged  his 
22-calibre  rifle  at  a  distance  of  about  one  hundred  and  fifty  feet,  the  bullet 
striking  the  patient  in  the  abdomen.  The  injury  caused  but  little  pain,  and 
immediately  after  the  accident,  the  patient  walked  about  forty  yards  to  a  farm 
house,  where  he  was  placed  in  bed.  From  there  he  was  conveyed  on  a  cot,  in 
a  farmer's  wagon,  to  the  Milwaukee  Hospital,  some  six  miles  distant.  The 
accident  occurred  about  noon,  and  he  arrived  at  the  hospital  at  3  p.  m. 

Examination.  Patient  complained  of  considerable  pain  in  the  abdomen; 
pulse  80  and  soft;  his  general  appearance  indicated  no  serious  injury.  On 
undressing  him,  a  bullet  wound,  with  omentum  protruding,  was  found  two 
inches  to  the  right  of  the  middle  line,  and  on  a  level  with  the  anterior  superior 
spine  of  the  ilium.  Left  iliac  region  dull  on  percussion;  and  in  right,  a 
cracked-pot  sound  was  elicited  on  percussion.  A  rectal  enema  was  adminis- 
tered, and  was  followed  by  a  free  faecal  discharge,  without  admixture  of  blood. 
On  washing  the  faeces  afterward,  the  bullet  was  found. 

Operation.  Ether,  as  an  anaesthetic;  thorough  disinfection  of  abdominal 
waU;  rectal  insufflation  of  hydrogen  gas,  followed  by  the  escape  of  bubbles 
of  the  gas,  within  a  few  seconds,  at  the  wound  of  entrance,  into  which  had 
been  placed  a  hsemostatic  forceps,  the  blades  separated  so  as  to  render  the 
canal  patent.  The  gas  was  lighted,  and  after  thorough  cauterization  of  the 
wound  by  the  flame,  was  extinguished  by  the  application  of  a  wet  sponge. 

Laparotomy  by  median  incision,  eight  inches  in  length,  from  pubes 
upward.  About  a  pint  of  fluid  blood  in  the  peritoneal  cavity,  and  haemor- 
rhage continuing  from  the  mesenteric  veins  at  two  points  of  perforation  on 
the  mesenteric  side  of  the  bowel,  and  to  a  less  extent  from  perforations  of  the 
mesentery,  arrested  by  ligating  en  masse.  Within  a  distance  of  four  feet, 
near  the  middle  of  the  ileum,  were  found  ten  perforations,  two  of  which  were 
at  the  mesenteric  border;  also  four  perforations  of  the  mesentery.  Another 
perforation  of  the  bowel  was  found  within  four  inches  of  the  ileo-caecal  valve 
on  the  convex  side  of  the  intestine,  making  so  far  eleven  in  all.  All  were 
closed  by  Czerny-Lembert  sutures.  At  two  points  the  perforations  were  so 
close  together  that  it  was  found  necessary  to  invert  half  the  circumference  of 

253 


254  INTESTINAL  SURGERY. 

the  bowel  on  the  convex  side,  thus  producing  considerable  narrowing  of  its 
lumen. 

Two  hours  had  been  consumed  in  arresting  the  haemorrhage  and  closing 
the  eleven  perforations,  and  the  patient  at  this  time  had  become  pulseless; 
yet  it  was  deemed  absolutely  necessary  to  determine  beyond  all  doubt  if  any 
more  perforations  existed,  by  repeating  the  rectal  insufflation  of  hydrogen 
gas.  On  repeating  this  test  it  was  found  that  gas  escaped  freely  from  the 
pelvic  cavity,  without  reaching  the  ileo-csecal  region,  showing  that  at  least 
one  more  perforation  was  below  this  point.  The  sigmoid  flexure  was  brought 
into  the  wound  and  compressed  between  the  index  finger  and  thumb.  Insuf- 
flation was  again  followed  by  escape  of  gas,  demonstrating  that  the  perfora- 
tion was  below  this  point.  Inch  by  inch  the  bowel  was  examined  by  this 
method  in  a  downward  direction,  until  a  perforation  was  found  in  the  anterior 
portion  of  the  rectum,  at  a  point  where  the  peritoneum  covering  its  anterior 
wall  is  reflected  upon  the  bladder,  This  perforation  was  rendered  accessible 
to  direct  treatment  by  an  assistant  making  traction  on  the  colon,  and  by 
keeping  the  margins  of  the  wound  well  retracted  by  means  of  a  pair  of 
Hegar's  retractors.  It  was  closed  by  five  Lembert  sutures,  with  the  greatest 
difficulty,  on  account  of  its  deep  situation,  and  the  inadequate  light  furnished 
by  two  candles. 

From  the  perforations  in  the  ileum  there  escaped  pieces  of  green  apples 
and  intestinal  contents,  and  from  that  in  the  rectum,  fluid  faeces. 

The  peritoneal  cavity  was  freely  irrigated  with  a  one-third  per  cent,  solu- 
tion of  salicylic  acid.  After  completion  of  peritoneal  toilet,  a  glass  drain  was 
introduced  in  such  a  manner  that  the  distal  open  end  was  placed  opposite  the 
sutured  rectal  wound,  and  the  abdominal  incision  closed  in  the  usual  manner. 

Whiskey  was  freely  administered  hypodermically  during  the  operation 
and  after  its  completion,  as  the  patient  remained  pulseless  for  half  an  hour. 

Time  of  operation  two  and  a  half  hours. 

The  foot  of  the  bed  was  elevated  and  dry  heat  applied  to  the  extremities. 

10  p.  M.  Temp.  99.5°  F.;  pulse  rapid  and  weak.  About  one  ounce  of 
bloody  serum  withdrawn  from  glass  drain. 

Sept.  10th.  8  A.  M.  Temp.  99°  F.;  pulse  126.  Clear  serum  only  in  the 
drain;  about  one  drachm  withdrawn  every  three  hours.  During  the  day  the 
patient  was  slightly  delirious,  and  in  the  absence  of  the  nurse  he  got  out  of 
bed  and  walked  across  the  ward  to  another  bed.  8  p.  m.  Temp.  99.8°  F.; 
pulse  144.  Some  tympanites.  Ordered  one  drachm  of  turpentine  in  half  a 
pint  of  warm  water,  as  an  enema,  which  was  followed  by  free  discharge  of 
faeces  and  flatus. 

11th.  Temp,  normal;  pulse  104.  Natural  passage  from  bowels;  delirium 
continues. 

12th.  Temp,  normal;  pulse  96.  Delirium  disappeared.  Allowed  liquid 
food  in  small  quantities. 

13th.  Pulse  72.  The  contents  of  the  glass  drain  have  a  suspicious  feecal 
odor.  Glass,  replaced  by  rubber  drain.  Slight  diarrhoea,  which  relieved  the 
tympanites. 


RECTAL  INSUFFLATION  IN   GUNSHOT    WOUNDS.  255 

14th.  9  A.  M.  Temp.  101°  F.;  pulse  126.  A  faecal  fistula  has  formed  along 
the  track  of  the  drainage-tube.  Large  rubber  tube  introduced  through  the 
anus,  and  left  in  rectum  to  allow  free  escape  of  fluid  f feces.  Fluid  injected 
into  fistula  does  not  flow  through  the  rectal  tube.  Rectum  disinfected  every 
four  hours  with  saturated  salicylic  acid  solution. 

17th.  Temp,  normal;  pulse  108.  Free  discharge  of  fluid  faeces  from 
rectal  tube  and  fistula. 

18th.  Sutures  removed  from  the  abdominal  incision;  only  deep  parts 
united;  granulating  surfaces  approximated  by  strips  of  adhesive  plaster  over 
an  antiseptic  compress. 

19th.  Fluid  flows  freely  from  fistula  through  the  rectal  tube.  No  faeces 
have  escaped  through  fistula  for  twelve  hours. 

20th.  Rectal  tube  withdrawn,  followed  by  return  of  faecal  discharge 
through  fistula. 

Oct.  1st.  The  discharge  of  faeces  through  the  fistula  has  been  gradually 
diminishing,  and  has  now  ceased. 

19th.  Fistulous  track  completely  closed.  Abdominal  incision  all  healed, 
except  a  small  granulating  surface  at  lower  angle. 

Patient  discharged  cured,  November  3d. 

Remaeks. — The  subjective  symptoms  in  this  case  four  hours 
after  injury,  and  after  transporting  the  patient  a  distance  of  six 
miles,  furnished  no  indications  whatever  of  the  extent  of  visceral 
injury  which  was  found  on  exploring  the  abdominal  <3avity.  The 
rectal  insufflation  of  hydrogen  gas  at  once  rendered  the  diagnosis 
positive,  and  pointed  out  the  necessity  of  treatment  by  abdominal 
section.  Eleven  perforations  were  found  and  sutured  without  much 
difficulty,  but  the  last  perforation  in  the  deepest  portion  of  the 
pelvis  could  not  have  been  found  by  any  other  means  of  diagnosis 
short  of  rectal  insufflation.  Had  this  perforation  been  overlooked, 
death  from  septic  peritonitis  would  have  been  inevitable.  Drainage 
was  resorted  to  in  this  case,  not  only  from  the  fact  that  faecal 
extravasation  had  taken  place,  but  also  for  the  reason  that  owing  to 
the  difficulty  in  gaining  access  to  the  rectal  wound,  I  feared  that  the 
suturing  was  not  as  perfect  as  it  should  be,  and  by  proper  drainage 
I  wished  to  prevent  possible  extravasation  into  the  peritoneal  cavity 
from  this  cause.  Subsequent  events  showed  the  propriety  of  this 
precaution. 

Case  II.  J.  E.  (case  of  Drs.  Gudden,  Steele,  and  Gordon,  of  Oshkosh), 
eighteen  years  of  age,  was  out  target-shooting  with  a  companion,  who,  while 
raising  his  22-calibre  rifle  to  his  shoulder,  accidentally  discharged  it;  the 
bullet  struck  the  patient  in  the  abdomen.  He  was  about  forty  feet  distant, 
and  almost  directly  facing  his  companion.     When  first  seen  by  Dr.  Gudden, 


256  INTESTINAL  SURGERY. 

within  half  an  hour  after  the  injury  was  received,  he  was  suffering  severe 
pain  in  the  abdomen,  was  pale,  covered  with  cold,  clammy  perspiration,  and 
vomited  frequently.  He  was  placed  in  a  carriage  and  conveyed  to  his  home, 
a  distance  of  two  miles.  During  the  journey,  the  severity  of  the  abdominal 
pain  was  so  increased  by  the  motions  of  the  carriage,  as  to  necessitate  repeated 
stops. 

I  saw  the  patient,  with  the  above-named  physicians,  October  9th,  4  a.  m., 
twelve  hours  after  the  accident. 

Examination.  The  wound  of  entrance  was  found  to  be  at  the  outer 
margin  of  the  left  rectus,  about  one  inch  below  the  level  of  the  umbilicus. 
Abdomen  dull  on  percussion  in  left  iliac  region,  pulse  140,  temperature  100°  F. 
Penetration  of  the  abdomen  was  proved  by  the  introduction  of  a  grooved 
director,  which  was  left  in  place  during  the  insufflatioil  of  the  hydrogen  gas. 

The  patient  was  placed  under  the  influence  of  chloroform,  and  during  the 
operation  the  narcosis  was  maintained  with  ether.  The  abdomen  was  thor- 
oughly disinfected,  and  rectal  insufflation  of  hydrogen  gas  practiced  to 
ascertain  if  any  perforation  of  the  intestine  existed.  Under  a  pressure  of 
about  half  a  pound  to  the  square  inch,  and  the  use  of  one-quarter  of  a  gallon 
of  gas,  in  a  few  minutes  the  gas  escaped  along  the  groove  of  the  director,  and, 
on  applying  a  match,  lighted  as  it  escaped.  The  flame  was  now  extinguished 
by  a  moist  sponge,  and  the  abdomen  opened  by  a  median  incision,  five  inches 
in  length,  extending  from  the  umbilicus  to  near  the  pubes. 

On  exposing  the  peritoneum  at  the  lower  angle  of  the  incision,  through 
this  membrane  there  was  observed  a  structure  closely  resembling  an  o-^er- 
distended  bladder.  That  this  structure  was  a  distended  bladder  was  improba- 
ble, as  the  patient  had  urinated  before  the  anaesthetic  was  administered.  The 
peritoneum  was  carefully  incised  between  two  forceps,  and  divided  upon  a 
grooved  director  to  the  same  extent  as  the  external  incision,  and  it  was  then 
discovered  that  what  appeared  to  be  an  over -distended  bladder,  was  a  coil  of 
small  intestine  distended  with  blood  to  twice  its  normal  size.  The  whole 
pelvic  cavity  was  found  filled  with  fluid  blood.  On  withdrawing  the  small 
intestine,  five  perforations  near  the  junction  of  the  jejunum  and  ileum,  and 
within  a  distance  of  three  feet,  were  found;  four  occurred  in  pairs  on  the 
lateral  aspect  of  the  bowel,  and  one  at  the  mesenteric  attachment.  All  the 
perforations  were  disproportionately  large  to  the  size  of  the  bullet,  and  would 
easily  admit  the  tip  of  the  index  finger.  The  intestine,  at  the  point  of  injury, 
was  covered  with  a  thick  layer  of  recent  plastic  lymph,  and  the  parietal  peri- 
toneum presented  all  the  evidences  of  a  beginning  diffuse  septic  peritonitis. 
The  intestine,  which  was  over-distended  by  blood-clots  for  about  three  feet, 
was  emptied  and  irrigated  with  a  one-third  per  cent,  solution  of  salicylic  acid, 
which  was  used  for  constant  irrigation  during  the  entire  time  required  in 
suturing  the  perforations,  which  were  closed  by  Czerny-Lembert  sutures. 

Further  examination  disclosed  four  perforations  of  the  mesentery,  from 
two  of  which  quite  profuse  venous  hsero-orrhage  was  still  going  on.  The 
haemorrhage  was  arrested  by  ligature  en  masse,  by  passing  a  needle  threaded 


RECTAL  INSUFFLATION  IN   GUNSHOT   WOUNDS.  257 

with  fine  silk,  through  the  entire  thickness  of  the  mesentery,  on  either  side  of 
the  perforations. 

Rectal  in^fflation  of  hydrogen  gas  was  repeated,  so  as  to  ascertain  if 
any  other  perforations  existed;  and  the  gas  after  it  had  been  gently  forced 
beyond  the  highest  perforation,  was  naade  to  traverse  the  balance  of  the 
entire  intestinal  canal  by  drawing  forward  loops  of  the  intestine  and  return- 
ing them  as  examined  without  further  insufiiation.  This  procedure  was  found 
entirely  satisfactory  and  practical,  as  the  gas  on  account  of  its  low  specific 
gravity,  readily  entered  the  highest  point  in  the  prolapsed  intestinal  loop. 

The  abdominal  cavity  was  irrigated  with  salicylic  acid  solution,  numerous 
coagula  removed,  the  toilet  completed,  a  glass  drain  introduced  into  the 
pelvis,  and  the  abdomen  closed. 

Duration  of  operation  two  hours.  Patient  collapsed,  pupils  greatly 
dilated,  and  almost  pulseless  in  spite  of  repeated  hypodermic  injections  of 
brandy,  which  were  administered  when  signs  of  collapse  became  apparent, 
throughout  the  operation.  Enema  of  a  teacupful  of  warm  water  and  two 
ounces  of  brandy.     Foot  of  bed  elevated  and  external  dry  heat  applied. 

In  an  hour  and  a  half  he  rallied  somewhat  from  the  operation,  but  again 
sank  and  died  at  3  p.m.,  eight  hours  after  the  completion  of  the  operation. 

Post-mortem  eighteen  hours  after  death  (Drs.  Steele,  Gudden,  Gordon). 
Circumscribed  peritonitis  present  at  time  of  operating,  now  diffuse;  very 
little  fluid  in  abdominal  cavity;  several  small  blood-clots  in  vicinity  of 
transverse  colon.  The  perforations  were  all  securely  closed,  and  the  bullet 
was  found  in  the  soft  tissues  to  the  right  of  the  spinal  column,  between  the 
fourth  and  fifth  lumbar  vertebrae,  and  near  the  ascending  colon.  The  bullet, 
though  only  of  22-calibre,  was  oblong,  and  may  thus  explain  the  unusually 
large  size  of  the  perforations. 

Remakes. — This  case  compared  with  the  foregoing,  furnishes  a 
strong  argument  in  favor  of  early  operative  interference  in  cases  of 
gunshot  or  stab  wounds  of  the  abdomen,  in  which  the  existence  of 
visceral  lesions  can  be  demonstrated  by  rectal  insufflation  of  hydro- 
gen gas.  In  the  first  case,  although  twelve  perforations  were  found 
and  sutured,  and  faecal  extravasation  had  taken  place,  no  evidences  of 
peritonitis  were  found,  and  the  patient  recovered.  In  this  case, 
twelve  hours  intervened  between  the  time  the  injury  was  received 
and  the  treatment  by  laparotomy,  during  which  time  a  septic  peri- 
tonitis had  developed,  the  extension  of  which  the  operation  did  not 
arrest,  and  from  the  eflPects  of  which  the  patient  died. 


17 


JNDEX. 


A  Page 
BDOMEN,  Diagnosis  by  rectal  insufflation  with  hydrogen  gas  of  gun- 
shot wound  of — with  reports  of  cases 253 

Diagnosis   by   rectal    insufflation   with    hydrogen  gas   of 
injury   of    gastro-intestinal    canal  in    penetrating 

wounds  of 215 

Rectal  insufflation  of  hydrogen  gas  in  diagnosis  of  gunshot 

wounds  of.     Experiments 239 

Abdominal  compression  in  intestinal  obstruction 22 

Section  in  intestinal  obstruction 27 

Tumors.     Diagnosis  of — by  inflation  with  hydrogen  gas 252 

Acquired  or  cicatricial  stenosis 123 

Acute  invagination.     Pathology  of 83 

Adhesion  experiments 199 

Adhesions  as  a  cause  of  intestinal  obstruction 104 

of  intestine.     Laparotomy  in 58 

After-treatment.     Laparotomy 61 

Age  of  invagination  patients 83 

Air.     Rectal  insufflation  of.     Experiments   222 

Alimentary  canal.     Force  necessary  for  rectal  inflation  of  entire — with 

hydrogen  gas.     Experiments 229 

Inflation  of — through  stomach-tube,  Experiments...   225 

Anaesthesia  in  laparotomy 33 

Anastomosis,  Intestinal 4:3,  177 

by  perforated  plates  in  jejuno-ileostomy.   Experi- 
ments     185 

by  sutures  in  jejuno-ileostomy.    Experiments...   183 

Experiments 45 

Illustrations 213 

in  gastro-enterostomy.    Experiments 180 

in  invagination 59 

in  pyloric  stenosis -"^O 

in  strangulated  hernia 52 

Operation 48 

Physiological  exclusion  by 52 

Anatomical  location  of  invagination 78 

Anatomico-pathological  forms  of  obstruction 62 

Appendix  vermiformis,  strangulation  by 114 

Apposition,  ileo-colostomy  by  lateral.    Experiments 192 

259 


260  INDEX. 

•  Page 

Artificial  intestinal  obstruction 146 

Ascarides,  intestinal  obstruction  from , 74 


B. 


)AND,  Laparotomy  in  strangulation  by 57 

Bands,  strangulation  by  ligamentous 110 

Biliary  calculi 62 

Bone-plates.    Illustrations 213 

Preparation  of  decalcified 179 

Bryant 15,   36,  81,  126 

Bull , , 9,  113,  133,  218 

r 

v^AijOUIjI,  Biliary  ^  ^  i  %  t»i«  4»«i  «•«•  !»«•  «k4t  *  iiii  .tt*  t***  it**  •• 62 

Carcinoma 131 

Catarrhal  and  ulcerative  enteritis 137 

Chemical  irritation  of  serous  surfaces.    Experiments 203 

Chronic  invagination,  pathology  of 86 

Cicatricial  or  acquired  stenosis 123 

Circular  constriction,  stenosis  by.     Experiments 147 

Enterorrhaphy 166 

Experiments 170 

Colo-rectostomy.     Experiments 198 

Colon,  distention  of,  with  fluids  in  intestinal  obstruction 8 

Excision  of.     Experiments 161 

Invagination  of,  into  rectum 81 

Resistance  of,  to  diastaltic  force.     Experiments 232 

Tubage  of,  in  intestinal  obstruction 16 

Colotomy  in  intestinal  obstruction 25 

in  invagination 89 

Compression  of  abdomen  in  intestinal  obstruction 22 

Conclusions,  intestinal  obstruction 208 

Rectal  insufflation  of  hydrogen  gas 247 

Concretions ,  intestinal 72 

Congenital,  non-malignant  stenosis 121 

Connel,  M.  E 144,  178,  222 

Constriction,  stenosis  by  circular.     Experiments 147 

Czerny-Lembert  sutures,  objections  to 167 


D: 


'ECALCIFIED  bone-plates,  preparation  of 179 

Definition  of  intestinal  obstruction 4 

Diagnosis  of  gunshot  -wound  of  abdomen  by  rectal  insufflation  with  hydro- 
gen gas,  with  reports  of  cases 253 

of  injuries  of  gastro-intestinal  canal  in  penetrating  wounds  of 

abdomen  by  rectal  insufflation  with  hydrogen  gas 215 

of  obscure  abdominal  tumors  by  inflation  with  hydrogen  gas . .   252 


INDEX.  261 

Page 

Diagnosis  of  perforation  of  stomach  by  inflation  with  hydrogen  gas 252 

of  wounds  of  the  stomach  by  inflation  with  hydrogen  gas,  with 

report  of  case 249 

Diastaltic  force,  resistance  of  gastro-intestinal  canal  to.    Experiments .  . .  231 

Directions  for  preparing  decalcified  bone-plates 179 

Disinvagination 95 

Distention  of  colon  with  fluids  in  intestinal  obstruction 8 

of  gastro-intestinal  canal  by  rectal  insufflation  of  hydrogen 

gas.    Experiments 233 

Diverticulum,  laparotomy  in  strangulation  hv 57 

Strangulation  by 110 

Strangulation  from  Meckel's 115 

Duodenum,  diagnosis  by  inflation  with  hydrogen  gas  of  ulcer  of .    252 

Dynamic  intestinal  obstruction  caused  by  suspension  of  peristalsis 134 


illNTERECTOMY ' 54 

Experiments 158 

Stenosis  by  partial.    Experiments 146 

Enteritis,  catarrhal  and  ulcerative 137 

Entero-lithiasis 62 

Enterotomy  in  intestinal  obstruction 22 

in  invagination 90 

Enterorrhaphy,  circular 166 

Experiments 170 

Examination,  intra-abdominal,  in  laparotomy 36 

Excision  of  colon.     Experiments 161 

Experimental  Contribution,  treatment  of  intestinal  obstruction 141 

Experiments,  Adhesion 199 

Chemical  irritation  of  serous  surfaces 203 

Circular  enterorrhaphy 170 

Colo-rectostomy 198 

Distention  of  gastro-intestinal  canal  by  rectal  insufflation  of 

hydrogen  gas 233 

Enterectomy 158 

Excision  of  colon   161 

Flexion 149 

Force  necessary  for  rectal  inflation  of   entire   alimentary 

canal  with  hydrogen  gas 229 

Force  necessary  to  overcome  resistance  of  ileo-ceecal  valve .  227 

Foreign  bodies 63 

General  remarks  on 144 

Ileo-colostomy  by  implantation 189 

Ileo-colostomy  by  lateral  apposition 192 

Ileo-colostomy  by  perforated  plates 195 

Ileo-rectostomy 197 


262  INDEX. 

Page 

Experiments,  Inflation  of  alimentary  canal  through  stomach-tube 225 

Innocuity  of  hydrogen  gas  in  contact  with  living  tissues. 

Experiments 238 

Intestinal  anastomosis 44 

by  perforated  plates  in  jejuno-ileos- 

tomy 185 

by  sutures  in  jejuno-ileostomy 183 

Invagination 152 

Mechanical  obstruction 135 

Nothnagel's  test 172 

Omental  grafting , 205 

Permeability  of  ileo-csscal  valve 157,  221 

Physiological  exclusion 163 

Rectal  insufflation  of  air 222 

Rectal  insufflation  of  hydrogen  gas  in  diagnosis  of  gunshot 

wounds  of  abdomen 239 

Resistance  of  gastro-intestinal  canal  to  diastaltic  force ....   231 

Stenosis  by  circular  constriction 147 

by  partial  enterectomy 146 

Transplantation  of  omental  flap 173 

Traumatic  irritation  of  serous  surfaces 200 

Volvulus 99,  151 

Perforated  plates  (not  bone) 178 

Exploration,  manual,  by  rectum  in  intestinal  obstruction 18 

Exventration 138 

\_  ^CES,  Intestinal  obstruction  from  retention  of 76 

Flexion  as  a  cause  of  intestinal  obstruction 104 

Experiments 149 

of  intestine,  laparotomy  in 58 

Force   necessary   for   rectal   inflation   of    entire   alimentary   canal   with 

hydrogen  gas.    Experiments 229 

to  overcome  resistance  of  ileo-caecal  valve.  Experiments.  227 

Foreign  bodies.     Experiments 63 

Treatment  of 70 

Frequency  of  intestinal  obstruction , 5 

(jALL-STONES,  Impacted 62 

Gastro-enterostomy,  intestinal  anastomosis  in.     Experiments 180 

Gastro-intestinal  canal,  distention  of,  by  rectal  insufflation  of  hydrogen  gas. 

Experiments 233 

injuries  in  penetrating  wounds  of  abdomen.     Diagnosis 

by  rectal  insufflation  of  hydrogen  gas 215 

Grafts,  Omental 60 

Experiments 205 


INDEX.  26^ 

Page 
Gunshot  wound  of  abdomen.     Diagnosis  by  rectal  insufflation  with  hydro- 
gen gas,  with  reports  of  cases 253 

Rectal  insufflation  of  hydrogen  gas  in  diag- 
nosis of.     Experiments 239 


XlERNIA,  Strangulated,  Anastomosis  in 52 

Heusner 68,  136 

Hydrogen,  rectal  insufflation  of  sulphuretted 221 

Hydrogen  gas,  Diagnosis  of  gunshot  wound  of  abdomen,  by  rectal  insuffla- 
tion of — with  reports  of  cases 253 

Obscure  abdominal  tumors  by  inflation  with . .  .   252 

Perforation  of  stomach  by  inflation  with 252 

Distention  of  gastro-intestinal  canal  by  rectal  insufflation 

of.     Experiments 233 

Force  necessary  for  rectal  inflation  of  entire  alimentary 

canal  with.    Experiments 229 

Inflation  in  diagnosis  of  wounds  of  the  stomach,  with  report 

of  case 249 

Innocuous  in  contact  with  living  tissues.     Experiments  .  .   238 

Method  of  rectal  insufflation  of 244 

Rectal  insufflation  of.    Conclusions 247 

in   diagnosis   of  gunshot  wound  of 

abdomen.     Experiments 239 

in  diagnosis  of   injuries  of  gastro- 
intestinal canal  in  penetrating 

wounds  of  abdomen 215 

in  intestinal  obstruction 12 

in  invagination   88 


I 


LEO-C^CAL  valve,  Force  necessary  to  overcome  resistance  of.   Experi- 
ments   227 

Permeability  of 218 

Permeability  of.    Experiments 157,  221 

Heo-colostomy  by  implantation.    Experiments 189 

by  lateral  apposition.    Experiments . . . .  ^ 192 

by  perforated  plates.    Experiments 195 

Ileo-rectostomy.     Experiments 197 

Illustration.     Intestinal  anastomosis 213 

Modification  of  Jobert's  suture 213 

Impacted  gall-stones 62 

Implantation  in  ileo-colostomy.     Experiments 189 

Incision  in  laparotomy 34 

Indications  for  operation  for  intestinal  obstruction 143 

Inflation  of  alimentary  canal  through  stomach  tube.     Experiments 225 


264  INDEX. 

Page 
Inflation  with  hydrogen  gas  in  diagnosis  of  obscure  abdominal  tumors . .   252 

perforation  of  the  stomach . .   252 
wounds  of  the  stomach.  Case.   249 

Innocuity  of  hydrogen  gas  in  contact  with  living  tissues.    Experiments.   238 

Insufflation,  Rectal,  of  hydrogen  gas  in  intestinal  obstruction 12 

Invagination 88 

Intestinal  Adhesions,  laparotomy  in 58 

Anastomosis 43,  177 

by  perforated  plates  in  jejuno-ileostomy.   Experi- 
ments    185 

by  sutures  in  jejuno-ileostomy.    Experiments....  183 

Experiments 45 

Illustrations 213 

in  gastro-enterostomy.    Experiments 180 

in  invagination 95 

in  pyloric  stenosis 50 

Operation 48 

Concretions 72 

Flexion,  laparotomy  in 58 

Obstruction,  Abdominal  section  in 27 

after  laparotomy 107,  109 

after  ovariotomy 59,  107,  109 

after  pelvic  peritonitis 109 

Anatomico-pathological  forms  of 62 

Artificial 146 

Colotomy  in 25 

Compression  of  abdomen  in 22 

Conclusions 208 

Definition  of 4 

Distention  of  colon  with  fluid  in 8 

Enterotomy  in 22 

Experimental  contribution  to  treatment  of .  .  141 

Flexion  and  adhesions  as  a  cause  of 104 

Frequency  of 5 

from  ascarides 74 

from  invagination 78 

•   from  retained  faeces 76 

from  round  worms 75 

from  suspension  of  peristalsis 134 

from  tumors 127 

Indications  for  operation 143 

Irrigation  of  stomach  in 6 

Manual  exploration  by  the  rectum  in 18 

Parasites  as  a  cause  of 74 

Puncture  of  intestine  in 20 

Rectal  insufflation  of  hydrogen  gas  in 12 


INDEX.  265 

Page 
Intestinal  Obstruction,  Risks  in  operation  for 144 

Surgical  resources  in 6 

Surgical  treatment  of 1 

Taxis  and  massage  in 19 

Tubage  of  colon  in 16 

Intestine,  Invagination  of  small — into  rectum 79 

Puncture  of,  in  intestinal  obstruction 20 

Intestines,  resistance  of  small— to  diastaltic  force.    Experiments 232 

Intra-abdominal  examination  in  laparotomy 36 

Intussusception,  laparotomy  in 92 

Invagination,  Age  of  patients 83 

Anatomical  location  of 78 

Colotomy  in 89 

Enterotomy  in 90 

Experiments 152 

Intestinal  anastomosis   in 95 

Intestinal  obstruction  from 78 

Laparotomy  in 91 

Mortality  of 83 

of  colon  into  rectum 81 

of  small  intestine  into  rectum 79 

Pathology  of  acute 83 

Pathology  of  chronic 86 

Rectal  insufflation  of  hydrogen  gas  in 88 

Resection  in 96 

Treatment  of 87 

Tumors  as  a  cause  of 80 

Irrigation  of  stomach  in  intestinal  obstruction 6 

Irritation,  chemical,  of  serous  surfaces.    Experiments 203 

traumatic,  of  serous  surfaces.    Experiments 200 

\J  EJUNO-ILEOSTOMY,   Intestinal   anastomosis   by   perforated    plates. 

Experiments 185 

Intestinal  anastomosis  by  sutures.  Experiments  183 

Jobert's  Suture,  Author's  modification  of 167 

Author's  modification  of.     Illustration 213 


KrOENLEIN 131 

Ktimmell 32,  34,     39 


L. 


jAPARO-ENTEROTOMY 54 

Laparatomy,  After-treatment 61 

Anaesthesia  in 33 


266  INDEX. 

Page 

Laparotomy  in  fleSf5n  of  intestine 58 

in  intestinal  adhesions 68 

in  intestinal  obstruction 27 

in  intussusception •  • •  •     92 

in  invagination 91 

in  strangulation  by  band  or  diverticulum 59 

Incision  in • •     34 

Intestiual  obstruction  after 107,  109 

Intra-abdominal   examination   in 36 

Preparations  for 32 

Statistics  of 28 

Leichtenstern 5,  66,  78,  83,  85,  87,  93,  152 

Lucas '••!«.  219 


MaDELUNG 8,  34,  38,  56,  127,  167 

Malignant  Stenosis 127 

Tumors , 129 

Manual  exploration  by  rectum  in  intestinal  obstruction 18 

Massage,  taxis  and,  in  intestinal  obstruction 19 

Maydl •■  •• 25,  124 

Mechanical  obstruction 134 

Experiment 135 

Meckel's  diverticulum,  strangulation  from 115 

Method  of  rectal  insufflation  of  hydrogen  gas 244 

Modification  of  Jobert's  suture.     Author's 167 

Illustration 213 

Mortality  of  invagination 83 


N. 


1  ON-MALIGNANT  Stenosis. 121 

Tumors 128 

Nothnagel's  test.     Experiments 171 


0 


BALINSKI 34,  105,  112,  138 

Objections  to  Czerny-Lembert  sutures 167 

Omental  flap,  transplantation  of 172 

Grafting.     Experiments 205 

Grafts 60 

Operation  for  intestinal  anastomosis 48 

for  intestinal  obstruction,  indications  for 143 

for  intestinal  obstruction.     Risks 144 

Operative  treatment  of  obstruction 43 

Ovariotomy,  intestinal  obstruction  after 69,  107,  109 


INDEX.  267 

PPage 

ARASITES  as  a  cause  of  intestinal  obstruction 74 

Pathology  of  acute  invagination 83 

of  chronic  invagination 86 

Pelvic  peritonitis,  intestinal  obstruction  after 109 

Perforated  plates,  ileo-colostomy  by.     Experiments 195 

in  jejunc-ileostomy,  intestinal  anastomosis  by.    Expe- 
riments    185 

(not  bone).     Experiments  with 178 

Perforation  of  stomach.     Diagnosis  by  inflation  with  hydrogen  gas 252 

Peristalsis,  suspension  of,  as  a  cause  of  intestinal  obstruction 134 

Peritoneal  cavity,  innocuity  of  hydrogen  gas  in.     Experiments 238 

Toilette  of 60 

Peritonitis 136 

Intestinal  obstruction  after  pelvic 109 

Permeability  of  ileo-cseeal  valve 218 

of  ileo-caecal  valve.     Experiments 157,  221 

Physiological  exclusion  by  anastomosis 52 

Experiments 163 

Plates,  ileo-colostomy  by  perforated.     Experiments 195 

(not  bone).     Experiments  with  perforated 178 

perforated,  in  jejuno-ileostomy,  intestinal  anastomosis  by.  Experi- 
ments    185 

Preparation  of  decalcified  bone 179 

Pleural  cavity,  innocuity  of  hydrogen  gas  in.     Experiments 239 

Pregnancy,  volvulus  in 102 

Preparation  of  decalcified  bone-plates 179 

Puncture  of  intestine  in  intestinal  obstruction 20 

Pyloric  stenosis,  intestinal  anastomosis  in 50 


R 


ECTAL  inflation  of  entire  alimentary  canal  with  hydrogen  gas.   Force 

necessary  for.     Experiments - 229 

Insufflation  of  air.     Experiments 222 

of  hydrogen  gas.     Conclusions 247 

of  hydrogen  gas.     Diagnosis  of  gunshot  wound  of 

abdomen  by — with  reports  of  cases 253 

of  hydrogen  gas.     Distention  of  gastro-intestinal 

canal  by.     Experiments 233 

of  hydrogen  gas  in  diagnosis  of  gunshot  wounds 

of  abdomen.     Experiments 239 

of  hydrogen  gas,  in  diagnosis  of  injury  of  gastro- 
intestinal canal   in  penetrating  wounds  of 

abdomen 215 

of  hydrogen  gas  in  intestinal  obstruction 12 

of  hydrogen  gas  in  invagination 88 

of  hydrogen  gas.     Method  of 244 


268  INDEX. 

Rectal  insufflation  of  sulphuretted  hydrogen 221 

Rectum,  invagination  of  colon  into 81 

Invagination  of  small  intestine  into 79 

Manual  exploration  by,  in  intestinal  obstruction 18 

Remarks  on  experiments 144 

Resection  in  invagination 96 

Resistance  of  ileo-csecal  valve.     Force  necessary  to  overcome.     Experi- 
ments    227 

of  gastro-intestinal  canal  to  diastaltio  force.     Experiments . . .  231 

Risks  of  operation  for  intestinal  obstruction 144 

Round  worms,  intestinal  obstruction  from 75 

Rydygier 94 


OAROOMA 129 

Serous  surfaces,  chemical  irritation  of.     Experiments 203 

Traumatic  irritation  of.     Experiments 200 

Small  intestines,  resistance  of,  to  diastaltio  force.     Experiments 232 

Statistics  of  laparotomy 28 

Stenosis,  acquired  or  cicatricial 123 

by  circular  constriction.     Experiments 147 

by  partial  enterectomy.     Experiments 146 

Malignant 127 

Non-malignant,  congenital 121 

Pyloric,  intestinal  anastomosis  in 50 

Stomach,  diagnosis  by  inflation  with  hydrogen  gas  of  ulcer  of 252 

Inflation  with  hydrogen  gas  in  diagnosis  of  wounds  of,  with 

report  of  case 249 

Irrigation  of,  in  intestinal  obstruction 6 

Perforation  of,  diagnosis  of  by  inflation  with  hydrogen  gas ....  252 

Resistance  of,  to  diastaltic  force.     Experiments 231 

Tube,  inflation  of  alimentary  canal  through.     Experiments ....  225 

Strangulated  hernia,  anastomosis  in 52 

Strangulation  by  band  or  diverticulum,  laparotomy  in 57 

by  ligamentous  bands  or  diverticula 110 

by  vermiform  appendix 114 

from  Meckel's  diverticulum , 115 

Subcutaneous  cellular  tissue,  innocuity  of  hydrogen  gas  in.     Experiments  239 

Sulphuretted  hydrogen,  rectal  insufflation  of 221 

Surgical  resources  in  intestinal  obstruction 

Treatment  of  intestinal  obstruction 1 

Suspension  of  peristalsis  as  a  cause  of  intestinal  obstruction 134 

Suture,  Author's  modification  of  Jobert's 167 

Modification  of  Jobert's.    Illustration 213 

Sutures,  intestinal  anastomosis  in  jejuno-ileostomy  by.     Experiments. . .  183 

Objections  to  Czerny-Lembert 167 


INDEX.  269 

TPage 

AXIS  and  massage  in  intestinal  obstruction 119 

Toilette  of  peritoneal  cavity 60 

Transplantation  of  omental  flap 172 

Traumatic  irritation  of  serous  surfaces.     Experiments 200 

Treatment  of  foreign  bodies 70 

of  invagination 87 

of  volvulus 103 

Treves 66,  78,  85,  92,  124 

Tubage  of  colon  in  intestinal  obstruction 16 

Tumor  as  a  cause  of  invagination 80 

Tumors,  intestinal  obstruction  from 127 

Malignant 129 

Non-malignant 128 

Obscure  abdominal,  diagnosis  of,  by  inflation  with  hydrogen  gas  252 

Tympanites 134 


U: 


LCERATIVE  enteritis 137 

Ulcer  of  stomach  or  duodenum,  diagnosis  of,  by  inflation  with  hydrogen 

gas 252 

V  OLVULUS 98 

Experiments , 99,  151 

in  pregnancy 102 

Treatment 103 


w 


OUNDS,  gunshot,  of  abdomen.     Diagnosis  of,  by  rectal  insufflation 

with  hydrogen  gas,  with  reports  of  cases 253 

of  the  stomach.     Diagnosis  of,  by  inflation  with  hydrogen 

gas,  with  report  of  case 249 

penetrating,  of  abdomen.  Diagnosis  of,  by  rectal  insufflation 

of  hydrogen  gas,  of  gastro-intestinal  injuries  in 215 


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